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SN - GIFT Ministry Intake Form

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code
(The above First and Last Name should be that of your child with special needs.)
*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:
*What is your child's understanding of Jesus?
*What are your desired goals/expectations for your child participating in our ministry?
*Which service will you most likely be attending?
Please select the GIFT Ministry activities in which your child would like to participate (check all that apply):
Anthem Art Class:
GIFT Buttons and Brownies:
GIFT Guys Workshop:
GIFT Fit:

Family Information

*Parent (1)/Legal Guardian's Name:
*Parent (1)/Legal Guardian's Relationship to Attendee:
*Parent (1)/Legal Guardian's Cell Phone Number:
*Parent (1)/Legal Guardian's Email Address:
Home Phone Number (if different from Attendee's Phone above):
Parent (2) Information (If no Parent (2), please provide information for an Alternate Emergency Contact.)
*Parent (2) (or alternate contact) Name:
*Parent (2) (or alternate contact) Relationship to Attendee:
*Parent (2)/Legal Guardian's Cell Phone Number:
Parent (2) Email Address:
Sibling (1) Name:
Sibling (1) Date of Birth:
Sibling (1) Gender:
Sibling (2) Name:
Sibling (2) Date of Birth:
Sibling (2) Gender:
If there are additional siblings, please provide the information here:

Medical Information

*Please list any medications or supplements your child is taking:
*Please list all allergies:
*Dietary restrictions, if any (i.e. GFCF, no dairy, etc.):

Disability Information

*Describe Disability Diagnosis, Special Needs and/or Medical Problems.
(Please be as open as possible, knowing we will not turn your child away nor discriminate on what is listed):
*Classroom/Playground behaviors to be expected (both positive and negative):
*What is your child's primary form of communication? (i.e. vocal, non-verbal, partial verbal, signs, etc.)
*Is vision okay?:
If no, please explain
*Is hearing okay?:
If no, please explain:
*Are there any restrictions from physical activity?:
Please list any restrictions:
*Please choose bathroom need:
If needed, please provide extra diapers/pull-ups and clothes for your child in case of an accident. 
Additional Bathroom Instructions (if applicable):
Please check any behaviors that your child displays:
biting self:
biting others:
stimming or rocking:
crying:
elopement/wanders/runs away:
meltdown/tantrum/emotional outbursts:
verbal outbursts/cussing:
scratching self:
scratching others:
hair pulling (self):
hair pulling (others):
prefers to be alone:
sudden/unexpected hitting (self):
sudden/unexpected hitting (others):
struggles with transitions:
seizures (grand mal):
seizures (other-please describe in box below):
spitting:
kicking:
howling/vocalizes other sounds:
throwing objects:
putting non-food items in mouth:
pinching (self):
pinching (others):
aggressiveness:
Please use this box to provide any additional information concerning the behaviors checked above:
Please describe any triggers and/or sensitivities (i.e., certain words, behaviors, environmental conditions, touch, loud music, lots of people, etc.):
Other information, including cool down and safety measures helpful for us to know how to best care for your child:
*What does you child like to do for fun?
*What are some things your child likes to talk about (or be talked to)?

Does your child have a behavior plan?

*If yes, please email a copy of the behavior plan and/or additional information that includes any behaviors and interventions below to darlah@stonebriar.org.
Antecedents of Behaviors
What happens before behaviors occur, if anything?
Behaviors
What are different behaviors that your child can display?
Consequences of Behaviors
What happens after behaviors occur, if anything?
Current Behavior Strategies/Supports
Please list any strategies that your child is using, i.e. first/then, positive reinforcement, negative reinforcement, picture schedules, etc.
Child's likes (reinforcers) and dislikes:
Any additional information that relates to your child:

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.
Please fill out the following information requested about your insurance. IF you do not have insurance please type "N/A" in all fields.
*Health Insurance Policy Holder's Name:
*Health Insurance Provider:
*Health Insurance Company Phone #:
*Health Insurance Policy Number:
*Health Insurance Group Number:

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

By my electronic signature provided below, I certify that I have read, understand and agreed to comply with the above statements and agreements.
*Parent's Electronic Signature (Full Name):
*Parent Date of Birth:
*Today's Date: