Buddies Intake Form

Please complete this form once per child.

Our Buddies program is designed for children of all ages who need extra attention. Our Buddies Team assists these children with transitions, social situations, emotional well-being and regulation, and other needs they may have. We love our Buddies and they are an important part of VIVA Kids!

Your name *

Last name

Email address *

Buddy Information

Participant’s Full Name *

By what name does the participant liked to be called? *

Nick name

Is attending to church a new experience? *

Yes

Other

Does he/she have a formal diagnosis(es)? *

Yes

Other

Medications - Any prescriptions we should know about? *

Yes

Other

Can participant use washroom independently? *

Yes

Other

Does the person need constant one‐on‐one assistance? *

Yes

Other

Communication *

Vocal – My kids use their voice

Sign Language

AAC - Using a device

Other

How would you describe his/her social relationships? *

Things your child enjoys (items, activities, places, food, colour smell, etc.): *

Things your child doesn’t like (items, situations, sounds): *

What is helpful for holding his/her attention? *

Area of strength: *

Area of needs: *

What are the triggers for outbursts or melt downs? *

(i.e. loud noises, being touched, transition without warning, etc.)

What are the signs of anxiety or that a meltdown is coming? *

(rocking, covering ears, flapping, vocalizations, etc.)

What calms the person down? *

(removal of stimulus, hugging, giving of “security” object, counting, removal from environment, etc.)

Are you willing to share a copy of his/her IEP or Behavior Intervention Plan? *

Yes

Other

Do you have a goal(s) you hope your child can achieve through this church/Sunday School experience? *

(The goal may be as simple as being able to participate in the service, receive Communion, etc.)

Is there anything else you would like us to know that hasn’t yet been covered? *

VIVA Church
hello@vivachurch.ca
905-725-5946

Church Center requires JavaScript to be enabled.

Here are some instructions to enable JavaScript in your web browser.

Check-In Calendar