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Request a Special Needs Buddy
Please fill out the form below and someone will be in contact soon.
Parent/Guardian First Name
Parent/Guardian Last Name
Email
Phone
Kid's First Name
Kid's Age
Date of Birth
Kid's Last Name
Gender
Grade
My kid has the following diagnosis, medical condition(s), or learning difference
What are some interests and motivating factors your kid responds to or enjoys?
Do you forsee any challenges with your kid participating in church programs? If so, what?
Please check any that apply
Short Attention Span/ Easily Distraced
Fine Motor Skills (Cutting/Pasting)
Gross Motor Skills ( Walking/Jumping)
Leaves Classroom Without Permission
Trouble with Sensory Experiences
Aversion to Water, Light, Mask, etc.
Tantrums/Meltdowns
Trouble w/ Following Directions
Hearing Challenges
Seizures
Difficulty Interacting with Peers
Aggresive Behavior
Speech Difficulties
Difficulty w/ Changes in Routine
Difficulty Remaining on Task
Difficulty Sitting in a Group
Tends to be Possessive
Seperation Anxiety
Difficulty Communicating
Difficulty in Social Settings
Shyness
My Kid:
Choose an option
Are there any other concerns you would like to share?
Submit
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