Accessibility Profile

*Any personal information provided will be retained and used in accordance with the Hope Bible Church (HBC) privacy policy available HERE.

Your name *

Last name

Email address *

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Phone Number *

Phone type

Child's Name *

Child's Birthday *

Format: DD/MM/YYYY

Child's Address (if different from above)

Emergency Contact

Emergency Contact First & Last Name *

Phone Number *

Phone type

Accessibility Information

Accessibility diagnosis *

Adaptive equipment used. *

What adaptive methods do you use at home to assist your child in communicating? (signing,flashcards, etc.) *

Describe methods your child's 1:1 caregiver can use to effectively communicate to your child in a classroom setting. Please take into account your child's preferred learning style (auditory, visual, etc.).

Is your child verbal? *

Describe your child's specific behavior pattern for the following situations. Please suggest methods that your child's 1:1 caregiver can use to help your child adapt in the classroom.

Transitioning from one activity to the next. *

Ability to understand and follow directions during an activity and ability to focus on a specific activity. *

Describe in detail how misbehaviour is handled at home and school (time out, take a walk, quiet time/room etc.). *

Describe in detail effective positive reinforcement methods used at home or at school. *

Does your child have a 1:1 at school? *

Current medication, if any.

Will you be bringing any tools to the classroom each week? (stuffed animal, toy, comfort item, etc). *

Please describe any medical conditions we should be aware of such as asthma, seizure disorder, diabetes or any emergency treatments that may be needed in the classroom. *

Is there a flight risk? (ie: will your child attempt to leave their Hope Kids' classroom) *

What are your child's special talents, gifts, or strengths? *

What does your child enjoy doing? Interests, hobbies, toys, activities, games etc. *

Sensory challenges *

Select all that apply

Dislikes certain textures

Sensitive to sounds such as loud, sudden noise

Sensitive to visual stimulation

Prefers not to be touched (unless asked or requested by child)

Sensitive to changes in routine or environment

N/A

Other

Child's preferences *

Select all that apply

Enjoys playing in a group

Enjoys playing alone

Enjoys sensory toys (soft, hard, bumpy, rough etc.)

Enjoys being with his/her peer group

Enjoys music

Enjoys stories

Enjoys physical contact with others (holding hands during a walk etc.)

Enjoys fine motor activities (colouring, cutting/pasting, beads etc.)

Enjoy gross motor activities (jumping, going for a walk etc.)

Other

Assistance needed for: *

Select all that apply

Toileting

Eating/drinking

Interaction with peers

Communication

Direction

Other

If assistance is needed for toileting, please elaborate.

Allergies *

Please list all, along with reactions and treatment.

Are there any fears your child may encounter in the classroom we should know about? *

Does your child have any aggressive tendencies? If so, please explain.

Can your child be integrated into their age-appropriate classroom? *

Is there anything else you'd like to communicate that maybe was not addressed above?

Confirmation, consent, and release:

1. I am the parent and/or have legal custody over the child listed above, and have the right to sign them up for Hope Kids, including under any custody arrangements affecting the child. I agree that conditions of custody, if applicable, shall be fully communicated in writing to Hope Oakville including, if requested by Hope Oakville, a photocopy of the section of any court order providing me visitation or other applicable rights.

2. I have completed the form above accurately and in particular, have included all relevant medical information.

3. I understand that my child may not be permitted to attend Hope Kids if they are ill and in the reasonable opinion of Hope Oakville, their participation would expose other children to an unacceptable risk of illness.

4. I understand care is taken for safety and good health of my child and they will be supervised. I acknowledge, however, participation in physical activities that may occur at Hope Kids carry with them an inherent risk. I agree that if my child is injured, provided every reasonable effort is made first to contact me and the other emergency contact(s) listed above, medical staff selected by Hope Oakville and attending my child, exercising due care, are permitted to provide proper medical treatment including medication and surgery for my child as deemed necessary.

5. In the unlikely event that my child is injured while participating in activities while at Hope Kids or en route to such activities my child and I relinquish all rights to recover damages for any and all injuries sustained by my child during or en route to activities. In consideration of Hope Oakville granting my child permission to participate in Hope Kids, I hereby release Hope Oakville, its elders, staff, employees, and volunteers from liability for injuries caused by negligence on their part.

6. I consent to images of my child taken at Hope Kids being used by Hope Oakville for future promotional and educational purposes both at Hope and elsewhere. I have read and understand this confirmation, consent and release, and I confirm and agree as set out above.

I have read and agreed to the confirmation, consent, and release. *

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Hope Bible Church Oakville
info@hopeoakville.ca
905-827-4888