JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Special Needs Child Form
Answers are not going to be shared and are confidential.
Information is being collected to help JCFamilies in the planning of activities and events.
If you have more than one chid with special needs, please fill one individual form for each.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Gender
*
Female
Male
Age of the Child
*
Your answer
Child's Guardian Name
*
Your answer
Child's Guardian Email
*
Your answer
Is the child enrolled in a school?
*
No
Yes
If yes, where?
Your answer
Is your child receiving therapy in the school?
*
yes
no
Is your child receiving therapy outside the school?
*
yes
no
What kind of activities would you be interested in enrolling your kid?
*
music
arts
sports
Other:
Required
What other extracurricular activities does your child attend?
*
Your answer
What would you prefer?
*
drop-off/ playdates
playdates with parents/responsible ones
Please briefly explain your child's needs:
*
Your answer
Preferred time for playdates:
*
morning
afternoon
Preferred length for playdates:
*
1 hour
2 hours
Does your child have needs for motor, social , sensory regulation, or behavior interventions?
*
motor
social
sensory
behavioral
Required
Is your child potty trained?
*
yes
no
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of JCFamilies.
Report Abuse
Forms
