Family Ministries: Care Plan
Child's Name:
*
Child's Birthdate
*
Ministry:
Kids (Babies - 5th grade)
Students (6th grade - 12th grade)
Parent/Guardian Name:
*
Parent/Guardian Address:
*
Parent/Guardian Address:
Parent/Guardian Address:
Parent/Guardian Address:
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Parent/Guardian Phone Number:
*
Parent/Guardian Email:
*
CedarCreek Campus you attend:
Findlay
Oregon
Perrsyburg
South Toledo
West Toledo
Whitehouse
Developmental Information
We desire to give every child an excellent experience. This care plan will help our team serve your child best. Complete all sections that apply.
Describe your child's communication (select all that apply)
Typical
Non-Verbal
Echolalic
Sign Language
Difficult to Understand
Other
Other
What is your child's developmental age?
What age group does your child best associate with?
List any significant medical or psychological diagnoses:
Does your child have any allergies that we need to know about?
My child uses an Epi-Pen
Yes
What activities, toys and reinforcements does your child really enjoy and respond well to?
What activities, toys and reinforcements does your child dislike and/or respond poorly to?
Are there any concerns or challenges with eating/toileting? (please note if your child is not toilet trained.)
Please select any behavioral difficulties that apply to your child, and rate the frequency in which the behaviors occur: (1 = Occurs rarely; 5 = Occurs often)
Runs / Wanders Off
1
2
3
4
5
Refuses supervision
1
2
3
4
5
Verbally abusive
1
2
3
4
5
Sexually inappropriate
1
2
3
4
5
Aggressive (bites, hits, etc)
1
2
3
4
5
Spits
1
2
3
4
5
Climbs
1
2
3
4
5
Other
How do you comfort your child when he/she is upset? How do you handle your child's misbehavior? How does he/she react?
Is there anything else we need to know about your child to give them the best experience?
We look forward to partnering with you to provide the best care for your child! A campus representative will connect with you soon!
Signature
*
Clear
Todays Date & Time
Administration and use of Epi-Pen
By signing, I ( ) agree to waive and release any and all liability for CedarCreek Church in the administration and use of the Epi-Pen. I agree to forever release and discharge CedarCreek Church and its staff and volunteers from any and all liability, claims, actions, rights of actions, damages, and expenses, including attorney expenses, arising out of or resulting from any injury, disease, or death in the use, failure to use or the administration of the Epi-pen. If my child cannot administer the Epi-Pen themselves, I allow CedarCreek Church staff and volunteers to administer the Epi-Pen.
Signature
Clear
Todays Date & Time
Submit