Special Friends Intake Form

Form Entry

Child's Name

Date of Birth

Primary Contact's Name

Relationship to Child

Phone Number

Primary Diagnosis

Autism Visually Impaired/Blind Cerebral Palsy Seizure Disorder Developmental Delays Down Syndrome Head Injury/Spinal Cord Hearing Impaired/Deaf Other

Mental Disability

Allergy Information

Sensitivities

Large Groups

Personality

Favorite Activities

Angry or Frustrated Behavior

Calming Interventions

Large Group or Playground Challenges

Additional Information

Submit