Embrace at Signal Pres Embrace Intake Form 2022-2023 Step 1 of 5 20% Family Name(Required) Email(Required) Date of Form Submitted:(Required) MM slash DD slash YYYY Child(ren) lives with:(Required) Mother Father Both Parents Other Primary GuardianName(Required) First Last Relationship to Child(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone(Required)Email(Required) Secondary GuardianName First Last Relationship to Child Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneEmail Continued Family InformationChild(ren) Name and Age:(Required)Please list full name and age of each child attending Embrace, one child per lineHow did you learn about Embrace? Emergency Contact Name(Required) In the event of an emergency, the following person is allowed to pick up my childEmergency Contact Relationship to Child(Required) Emergency Contact Phone(Required) Child Name First Last Preferred Name/Nickname Untitled Gender(Required) Male Female For females only: Has your daughter had a menstrual period? Yes No Birthdate(Required) MM slash DD slash YYYY Age(Required) If your child attends school, please list name of school Grade in school State diagnosis or describe your child's disabilityCurrent medicationsActivities my child likes (examples: music, reading, art activities, physical games, independent play)My child needs encouragement toMy child does NOT enjoyPlease don't ask my child toMy child learns and participates best when the teacher:Vision Impaired Blind Hearing Impaired Deaf Hearing Aid Motor Skills Impaired Motor Skills Uses walker Uses braces Uses wheelchair Please explain any of your child's physical needs:Toileting Skills(Required) Toilets independently Potty trained, needs assistance Currently being potty trained Wears diaper Other Please list any toileting concerns you may have:Allergy InformationPlease list any food allergies:(Required)Please list any additional allergies:Appropriate response to allergy:Additional information regarding your child's allergies or eating habits:Communication with OthersCommunicates with others using: Sentences Phrases Words Babbles Gestures Sign Language Can understand what others say:(Required) All of the time Most of the time Some of the time Behavior(Required) Outgoing Shy Plays in groups Adapts to new situations well Adapts to new situations with difficulty Responds to correction well Responds to correction with difficulty Is sometimes destructive Sometimes threatens others Sometimes hits, bites, or hurts others/self Sometimes attempts to run away Hyperactive and/or ADD Other Does your child have an FBA (Functional Behavior Assessment)?(Required) Yes No Helpful tips for communicating with my child.Are there any behaviors/phrases that you anticipate we might need help interpreting?My child responds to separation from his/her parents by:My child is best comforted by:My child lets someone know what he/she needs by:What oppositional behavior might we encounter with your child and how do you handle this behavior at home or at school? Please be specific so that we can provide consistent care.Is there any other information that would be helpful for us to know to best care for your child?Great topics of conversation with my child:Fears or dislikes:Guardian Release InformationI understand that pictures and film my be taken at Signal Pres for the purposes of publicity, pictorial recordings, and identification. I give my permission for my child(ren) to be photographed while at Signal Pres.(Required) Yes No I will provide all diapers, clothing, and needed supplies for my child(ren) while attending Signal Pres. I understand that the staff cannot provide these items for my child(ren).(Required) I agree I disagree I authorize Signal Pres to administer medical assistance in case of an emergency. I understand that in case of a medical emergency, 911 will be called. Upon arrival, EMS will administer emergency assistance and if necessary, my child(ren) will be transported to the nearest medical facility for treatment. I understand that I will be contacted by NightOWLS staff via the phone numbers I provided at the check-in desk. I understand that we will be responsible for payment of all EMS, hospital, and physical charges for emergency services for my child(ren).(Required) I agree I disagree I have fully disclosed to SMPC all pertinent facts about my child’s special needs and accept full responsibility for failure to do so.(Required) I agree I disagree Electronic SignatureI acknowledge that it is my responsibility to notify the Embrace Director, in writing, of any changes or revisions to my/our child/children's information contained in the application.(Required) I agree I acknowledge that it is my responsibility to notify the Embrace Director, in writing, of any changes or revisions to my/our child/children's information contained in the application.(Required) I agree Signature Name(Required) Signature Date(Required) MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
