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SN - Special Needs Student Information

Special Needs Student Information - Stonebriar Community Church GIFT Ministry

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code
*Date of Birth:
*Gender:
For the question below, Sept-May: enter the current grade, June-Aug: enter the last grade completed. If your child is not in school, type N/A):
*Grade:
School or Day Program Name:
Family Information
*Parent(s) First and Last Name(s):
*Legal Guardian's Name and Relationships (If student not living with parent(s)):
Two names must be listed above. If not, please list additional emergency contact and relationship.
*Cell Phone Number (1) to be used while student is in our care:
*Cell Phone Number (1) belongs to:
*Cell Phone Number (2) to be used while student is in our care:
*Cell Phone Number (2) belongs to:
*Preferred Email Address to receive important information:
*Preferred Email Address belongs to:
Additional Email Address:
Additional Email Address belongs to:
*Siblings Names, Genders, and Dates of Birth (if none, type N/A):
Additional family information (student lives with grandparents, student lives alone, multiple households, etc.):

We collect the following information to make sure your child has the best experience while in our care. Please be as open and honest when answering these questions; your child will not be turned away nor discriminated against because of what is noted. 

Each question must be answered; if it doesn’t apply, write N/A. 
*What does he/she know about Jesus?

*What are his/her strengths?
*What are his/her current goals (big or small)?
*What does he/she like or dislike to do for fun or to talk/think about?
*How does he/she communicate (vocal, non-verbal, knows some words, signs)?
*Describe the student’s disability, including diagnosis:

*Describe any medical issues (seizure disorders, feeding tubes, etc.): 
*How is his/her vision and hearing (legally blind, sensitive to light, wears hearing aids, prefers headphones)?
*Does he/she have any restrictions from physical activity (falls easily, fragile, needs a helmet)?
*Please describe his/her bathroom needs (wears diapers, potty-training, some support needed, independent):
*List dietary restrictions, if any (i.e. gluten free, dairy free, no church snacks):

*List and explain all behaviors he/she displays. 

(You may copy and paste any of these or write your own: biting self or others, stimming or rocking, crying, elopement/wanders/runs away, meltdown/tantrum/emotional outbursts, verbal outbursts/cussing, scratching self or others, hair pulling self or others, prefers to be alone, sudden/unexpected hitting self or others, struggles with transitions, spitting, kicking, howling/vocalizes other sounds, throwing objects, putting non-food items in mouth, pinching self or others.)

*What triggers any of the above behaviors (i.e., certain words, behaviors, environmental conditions, touch, loud music, crowds)?

*What signs does your child give that indicates s/he may be getting upset (gets quiet, starts pacing, raises voice)?
*How do you resolve behavior issues at home or at school? What are your child’s rewards/consequences for both good and bad behavior?  

*What strategies and supports work well with your child (first this/then that, picture schedules, timers)?
If your child has a behavior plan, we’d like to incorporate that into your child’s Sunday routine. You may email it to darlah@stonebriar.org.
*What else can we do to help your child have the best experience while in our care?
There are several things parents can do to help us keep everyone safe and programs run as smoothly as possible. Please indicate you understand the following:
*Snacks are offered only for children up to age 11 in the Children’s Suite. If my child is in the Tweener’s Suite and is staying both services, I may send a snack clearly marked with their name. Snacks are not allowed in the John 9:3 classroom. Please do not bring treats to share.
*Parents need to take their child to the restroom before dropping them off. If your child is prone to accidents, send a change of clothing. Parents may be called to assist with bathroom/diaper needs if medical equipment is involved or the student is older.
  Consent for Treatment in Event of Accident/Injury  In the event of an accident or injury, I hereby give my permission for the physician/dentist selected by Stonebriar Community Church (SCC) to secure proper treatment for the above-listed person as deemed necessary.  I also authorize SCC staff and volunteers to administer medical aid as required for injury in the event that I cannot immediately be contacted.
*A "yes" is your signature that you've read and agree.




STONEBRIAR COMMUNITY CHURCH
 


Minor Photo Release Form
 


 For myself and for and on behalf of my child(ren) identified in this authorization (referred to as “Minor”), I hereby agree, represent and authorize as follows:


 


I grant Stonebriar Community Church, its successors, assigns and licensees (collectively, the “Church”) permission to use, reproduce, publish, broadcast, stream, and exhibit in any medium, the Minor’s portrait, photograph, image, voice, works of authorship, writings and statements in any form (collectively, the “Product”) which are created, captured or developed by or for the Church in connection with the Minor’s participation in Church events or activities. 


 


I irrevocably authorize the Church to edit, alter, copy, exhibit, publish or distribute the Product in all forms and media or technology now known or hereafter developed and in all manners for advertising, publicity, commercial, promotion, trade, or other lawful purpose. I waive the right to inspect or approve the finished Product. I waive any right to royalties or other compensation related to the use of the Product.


 


I hereby hold harmless and fully release the Church, its agents, volunteers, licensees, employees, and representatives from all claims, demands, and causes of action that I and/or the Minor, or our respective heirs, representatives, executors, administrators, or any other persons acting on my behalf, the Minor’s behalf, or on behalf of our respective estates, have or may have due to this authorization or the Church’s use of the Product as permitted herein.


 


I am the parent and/or legal guardian of the Minor and that my parental and/or legal guardian rights include the ability to sign this agreement on behalf of the Minor. I give my consent and authorization without reservation to the terms herein on behalf of the Minor.


 


I am 18 years of age or older and am competent to contract in my own name. I read this agreement and release before signing and I fully understand its contents.


v.10.13.2018




*Image Release:
Assumption of Risk, Voluntary Release, and Indemnity Agreement
STONEBRIAR COMMUNITY CHURCH

ASSUMPTION OF RISK, VOLUNTARY RELEASE, AND INDEMNITY AGREEMENT

PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.  THIS IS A LEGAL DOCUMENT.  THIS FULLY SIGNED FORM MUST BE SUBMITTED BY A PARENT OR LEGAL GUARDIAN BEFORE ANY CHILD IS ALLOWED TO PARTICIPATE IN THE MINISTRY EVENT.

In consideration for the undersigned or the undersigned’s dependent (“Participant”) being permitted to participate in the event(s) described on Exhibit A, and any other activities connected with the event(s) described on Exhibit A (collectively the “Ministry Event”), the undersigned (“I” or “Me”) agrees as follows:

  1. ASSUMPTION OF RISK AND REPRESENTATION. I understand, am aware, and assume all risks, both known and unknown, inherent in Participant’s participation in the Ministry Event.  The known risks include those listed on Exhibit A, and may also include, but are not limited to, the hazards of road transportation, service projects, construction projects, illness or accident without immediate access to medical facilities, and the forces of nature, (collectively, the “Risks”).  Any of the Risks may result in serious bodily injury, temporary or permanent disability, or death, as well as economic and property loss.  I represent that I (or Participant) possess the necessary skills and fitness to safely participate in the Ministry Event(s).
  2. RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE. I, on behalf of myself and Participant, and our respective personal representatives, assignees, insurers, heirs, executors, administrators, spouse and next of kin, (collectively, the “Participant’s Parties”), hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Stonebriar Community Church and its directors, officers, employees, agents, volunteers, as well as its/their successors, assigns, affiliates, subordinates, and subsidiaries (collectively, the “Church”), and RELEASE, WAIVE AND DISCHARGE the Church from any and all liability to the Participant’s Parties for any and all loss, damage, injury, death, and expense to me or the Participant or his/her/our property, whether caused by negligence, or otherwise (except not for any gross negligence or willful misconduct on the part of the Church), while I am, or the Participant is, participating in the Ministry Event described in Exhibit A.
  3. INDEMNITY. I AGREE TO INDEMNIFY THE CHURCH FROM ANY LIABILITY, LOSS, DAMAGE OR COST THAT MAY ARISE FROM MY OR PARTICIPANT’S PARTICIPATION IN THE MINISTRY EVENT, WHETHER CAUSED BY THE NEGLIGENCE OF THE CHURCH OR OTHERWISE (EXCEPT NOT WHERE CAUSED BY ANY GROSS NEGLIGENCE OR WILLFUL  MISCONDUCT OF THE CHURCH).  I, FOR MYSELF AND PARTICIPANT, ASSUME FULL RESPONSIBILITY FOR, AND RISK OF, BODILY INJURY, DEATH OR PROPERTY DAMAGE DUE TO THE NEGLIGENCE (BUT NOT FOR GROSS NEGLIGENCE OR WILLFUL MISCONDUCT) OF OTHER PARTICIPANTS IN THE MINISTRY EVENT, OR OTHERWISE, WHILE I OR PARTICIPANT PARTICIPATE IN THE MINISTRY EVENT.
  4. ARBITRATION. I agree to resolve any dispute arising under or relating to this Agreement through a mutually acceptable alternative dispute resolution process. I further agree to notify the Church in writing as soon as reasonably possible of any dispute regarding this Agreement. If I, as the Participant or as parent/guardian of the Participant, and the Church, cannot agree upon a process within thirty days of the Church’s receipt of my notice, the dispute shall be submitted exclusively to the mediation and arbitration procedures of the Institute for Christian Conciliation/Peacemaker Ministries (www.hispeace.org).  Venue for the dispute resolution processes shall be exclusively in Collin County, Texas.
  5. I agree that the provisions of this Agreement are intended to be as broad and inclusive as permitted by the laws of the State of Texas, and that, if any portion of this Agreement is held invalid, it is agreed that the balance, notwithstanding, shall continue in full legal force and effect. I further agree that:
    1. I HAVE CAREFULLY READ THIS AGREEMENT, AND I HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT THIS DOCUMENT.
    2. I UNDERSTAND THAT THIS SIGNED RELEASE AGREEMENT WILL BE SCANNED INTO THE CHURCH’S DATABASE.  I FURTHER UNDERSTAND THAT IF THE ORIGINAL EXECUTED AGREEMENT IS DESTROYED, THE SCANNED COPY WILL BE DESIGNATED THE RECORD COPY AND RETAINED FOR THE APPROPRIATE PERIOD OF TIME.
    3. I UNDERSTAND THAT I AM AGREEING TO RELEASE ALL CLAIMS AGAINST THE CHURCH, INCLUDING NEGLIGENCE AND TO INDEMNIFY THE CHURCH AS STATED ABOVE.
    4. I CERTIFY THAT I AM EITHER (1) AT LEAST EIGHTEEN (18) YEARS OF AGE, OR (2) THE LEGAL GUARDIAN ACTING ON BEHALF OF THE PARTICIPANT WHO IS UNDER EIGHTEEN (18) YEARS OF AGE.
I VOLUNTARILY SIGN MY NAME EVIDENCING MY UNDERSTANDING AND ACCEPT THE PROVISIONS OF THIS AGREEMENT. 

Orig. 03202015/Revised 03052018

The GIFT Team appreciates your input and ask you keep us informed on any new information that will help us best serve your family. Contact us if you ever have any concerns or questions. Our desire is for your child to love attending so they may learn how much God loves them and He has a great plans for them!
By my electronic signature provided below, I certify that I have read, understand and agreed to comply with the above statements and agreements.
*Parent/Legal Guardian Electronic Signature (Full Name):
*Parent/Legal Guardian Date of Birth: