In HIS Image Family Registration
We welcome your child and look forward to serving your family while you are at Home Church. Please let us know how we can best prepare and respond to your child as we seek to get to know them better. Thank you for entrusting them to our care.
Personal
Child's Name
First Name
Last Name
Gender
Male
Female
Birth Date
-
Month
-
Day
Year
Date
Age
Child Lives With:
Both parents
Mother
Father
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Father's Name
First Name
Last Name
Address (If Different From above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Name
First Name
Last Name
Address (If Different From Above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Backup Emergency Contact
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Siblings Names & Ages
Medical
Specific Type of Disability/Diagnosis
Medical treatments, medications, allergies, or health support that anyone supporting & caring for your child should know?
Specific behaviors that may indicate your child is experiencing a medical problem requiring immediate attention
If your child is prone to seizures, describe the physical signs that indicate a seizure is in progress or may be imminent
Care & Comfort
What soothes your child?
What are some signs that let us know they need down time?
What type of assistance will your child need with transitioning, or using the restroom?
What are your child’s strengths?
What do you consider to be their greatest challenge in social settings?
Is there anything else you would like to share about your child?
Communication
Your child can communicate with other using (check all that apply)
Single Words
Phrases
Sentences
Babble
Gestures
Sign Language
Other
What language is spoken at home?
Your child can understand what others say
All of the time
Most of the time
Some of the time
What desire/need might your child be trying to communicate when they exhibit a specific behavior? Describe the desire/need and the behavior.
What are your child’s reading and writing levels?
In what ways does your child learn best? Describe teaching strategies that work particularly well.
Activities & Environment
What activities does your child enjoy most?
Does your child enjoy music?
Yes
No
Your child seems most relaxed when
Alone
With a few children
Among many children
Would your child enjoy a large group worship experience?
Yes
No
What are your goals/dreams for your child with regard to the church environment?
What are your biggest concerns for this environment?
What church programs (e.g., Sunday School, Youth Group, etc.) would you like your child to attend this year? Please indicate grade level.
What spiritual goals and concepts would you like us to focus on with your child?
For older children, what are your child’s gifts or talents that could be a contribution to the family of Christ?
Any additional information you would like to share with us?
Permission/Authorization Agreement
BY CLICKING SUBMIT, I INDICATE THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS.
I understand that the information regarding my child will be share by the screened and trained team members of In His Image Ministry.
Yes
I have fully disclosed to Home Church all pertinent facts about my child(ren)’s special needs and accept full responsibility for failure to do so.
Yes
I will supply all required food, drink, snacks and diapers/wipes for my child/ren.
Yes
In case of emergency or accident, I understand that every effort will be made to contact me, but if deemed necessary an EMS company (911) may be summoned. I authorize EMS to administer any medical treatment, medication, or appliance deemed necessary by EMS. I also authorize transportation by EMS to the nearest appropriate medical facility, as determined by EMS. I understand that I will be responsible for payment for all EMS, hospital, and physician charges for emergency services to my child.
Yes
Name of Parent/Guardian
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: