Liquid Kids Special Needs Registration

Liquid Family Special Needs Inclusion Registration

Our Buddy Program was designed so that children with special needs can participate in all kids' environments (birth - 8th grade) during weekend services. Our goal is for every child to be supported through the one-on-one care and attention of a buddy (aide).

Please fill this form out with as much detail as possible as this will help us plan for the best experience for your child.

Campus you attend*

Middlesex County - Sayreville Mercer County - Princeton Morris County - Parsippany Passaic County - Wayne Somerset County - Somerville Union County - Garwood Union County - Mountainside

Child's Name*

First Name

Last Name

Nickname*

Parent's Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email*

Child's date of birth*

My child is*

My child's current grade*

Please indicate "NA" if not applicable

Tell us what is wonderful about your child:*

My child's specific diagnosis:*

How this diagnosis affects my child physically:*

How this diagnosis affects my child emotionally:*

Is your child prone to eloping/running off? If so, what are the triggers and how do you handle it?*

Things to avoid that might "set my child off": *

Soothing/calming routines:*

My child is sensitive to (ex. indoor/outdoor light, loud sounds, specific textures):*

My child needs extra time/patience from you concerning: *

Other helpful behavioral information: *

My child's communication is primarily: *

Verbal Verbal & speaks clearly Non-Verbal Requires clues to initiate Uses assistive technology Uses eye gazes to communicate wants/needs Signs

Please give examples or explain the communication selected from the previous question: **

Familiar words/signs my child uses (ex. ba-ba for bottle, sign for outside)

If not applicable, indicate NA

Mobility is impacted*

Not at all Mildly Moderately Profoundly

My child

Uses a walker Uses a wheelchair Uses crutches Falls easily

Eating concerns*

Self feeds easily Needs prompts to eat Requires supervision/assistance Uses special utensils Uses a G-Tube

Other:

My child is*

Please note that parents will be called to take their child to the bathroom if assistance is needed. Our staff is prepared change diapers up to age 2.

My child's interests include: (favorite toy, preferred activities, etc.)*

Please share anything else you think might be helpful for us to know about your child: