Family Registration- Care Plan

Please fill out this form and click submit.

Parent Contact Information

Parent Name (s)

*

Parent Address

*

Cell Phone

*

Email

*

This address will receive a confirmation email

Child's Information

Child's Name

*

Birth Date

*

Age

*

Grade

Allergies

I give Movement permission to use my child's picture on their website, social media, or other promotional videos/pictures promoting Kids on the Move.

*

Please select one option.

yes no Option

Developmental Information

We desire to give every child an excellent experience. This care plan will help our team serve your child best. Complete all sections that apply.

Describe your child's communication.

Please select all that apply.

typical non-verbal echolalic sign language difficult to understand Other

What age group does your child best associate with?

List any significant medical or psychological diagnoses?

What activities, toys, and reinforcements does your child really enjoy and respond well to?

What activities, toys, and reinforcements does your child dislike or respond poorly to?

Are there any concerns or challenges with eating/toileting?

Please click any behavioral difficulties that apply to your child, and rate the frequency in which the behaviors occur. (1-occurs rarely; 5-occurs often)

Runs/wanders off

Please select all that apply.

1 2 3 4 5

Refuses supervision

Please select all that apply.

1 2 3 4 5

Verbally abusive

Please select all that apply.

1 2 3 4 5

Sexually inappropriate

Please select all that apply.

1 2 3 4 5

Aggressive (bites, hits, etc)

Please select all that apply.

1 2 3 4 5

Spits

Please select all that apply.

1 2 3 4 5

Climbs

Please select all that apply.

1 2 3 4 5

Other behavioral difficulties we should know...

How do you comfort your child when he/she is upset?

Is there anything else we need to know about your child to give them the best experience?

Expected service to attend the first time.

Please select one option.

9:00AM 10:45AM

Description

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