Kids | One-to-One Application

WHERE IT SAYS "YOUR NAME," PLEASE PUT THE NAME OF THE CHILD WHO WILL RECEIVE SERVICES.

Your name *

Last name

Email address *

Birthdate

Gender

Household members

Please complete this information regarding each member of the household.

Address

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Medical

Has your child been diagnosed by a medical professional?

Yes

Does your child receive any kind of therapeutic services?

Yes

May we contact their therapist(s)/service professional(s), if needed?

Yes

Is your child on medication?

Yes

Please check any of the following medical devices your child uses:

Hearing Aid

Cane/Crutches

Walker/Wheelchair

Artificial limb(s)

Any prosthetic

Other

Are there any other health concerns or conditions you would like us to know about?

Educational

Is your child in school?

Yes

Independance

Does your child take care of their own bathroom needs?

Yes

Does your child feed themself?

Yes

Does your child need assistance traveling from place to place?

Yes

Behavior

Does your child's behavior require the assistance of a one-to-one volunteer, otherwise called an "Angel"?

Yes

Please describe the behavior:

What do you do to control the behavior?

How does your child react to people they don't know?

Please check any of the following areas in which you would like to receive information:

Obtaining help or services for my child

Locating support groups

Locating respite programs

Locating recreation and leisure programs for my child

Resources relating to my child's specific disability

Other

Food

Does your child have any allergies?

Dairy / Lactose

Gluten

Eggs

Nuts

Bees

Penicillin/Amoxicillin

Epi Pen required

Other

Does your child require specifc foods or assistance with snack?

Yes

Communication

Is your child's speech understandable to people other than you?

Yes

How does your child communicate?

Sign language

Language board

Verbal

Other

Religious

Please describe any previous church experience your child has had (both positive and negative):

What is the religious background of your child's family?

Characteristics

What are your child's strengths?

What are your child's areas of difficulty?

What motivates your child?

Ex: verbal praise, high fives, candy, specific toy

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ACAC
pco.support@acac.net
4123214333