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The Ark - Child registration

The Ark is designed to serve children with special needs in a way that shows God's love uniquely to each child. In order to help the team best minister to your child and to your family, please fill out the following questions with as much detail as possible.

The Ark is designed to minister to children aged 2-12. Special accommodations may be made for children over the age of 12 with prior approval. Please contact Felicia, the director for The Ark, at felicia@crcbelton.com with any questions.

Your name *

Last name

Email address *

Name of child to attend The Ark *

Gender *

Birthdate *

Child Medical Information

Please fill out to the best of your ability. The more we know, the better we can serve you.

Diagnosis *

Additional Medical Needs

Behavioral Information

Triggers

What do you do to calm your child down if needed?

What does your child like? Interested in?

Food and Allergy Information

Please list any allergies.

If there are allergies, what reaction will there be?

Please list any dietary restrictions.

Additional Information

Does your child need assistance using the restroom?

yes

no

Does your child need assistance feeding themselves?

yes

no

Is your child used to being away from his/her parents?

yes

no

Does your child have a prosthetic device?

yes

no

Parent/Guardian approval

May The Ark staff assist if restroom help is needed? *

yes

no

May The Ark staff assist if help with food is needed? *

yes

no

Is it ok to take your child's photo for social media/website usage? *

yes

no

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Crossroads Church
info@crcbelton.com
2549392122

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