Custom Form

Buddy Ministry Inuiry

Thank you for inquiring about Nativity's Buddy Ministry. Please fill out the form below and we will be in contact with you shortly.

First Name

Last Name

Mobile Phone

Address Line 1

Address Line 2

City

State

Postal Code

Child's Name

Child's Nickname

Child's Birthday

Child's Grade Level

Parent/Guardian Name(s)

Cell Phone

Email Address

What allergies does your child have? Put N/A if none.

What medical needs should we be aware of? (e.g. seizures, mobility concerns, special equipment, etc.)

Does your Child need assistance Toileting?

If your child needs assistance indicating need for bathroom, please explain.

If your child needs assistance Following a toileting schedule please explain

If your child needs assistance reminders to complete bathroom routine, please explain

If your child needs assistance with mobility/balancing while using the bathroom, please explain

If your child needs assistance Managing clothing while using the bathroom, please explain:

If other, please explain bathroom assistance needs

How will your child communicate bathroom needs?

What upsets your child? (noises, lights, changes in routine, separation from parent, etc.)

What is calming for your child? (quiet space, low lighting, distraction with favorite toy/activity, etc)

What would you like us to know about your child?

What are your hopes of the Buddy Ministry for your child?

What are some of your child's favorite things?

What program is this child currently attending?

I understand the information on this form will be shared confidentially with ministers serving my child