Embrace Ministry

For families with exceptional needs

NightOWLS Child Form

Step 1 of 11

Family Name(Required)

Email(Required)

Date of Application(Required)

MM slash DD slash YYYY

We prefer to attend NightOWLS on:(Required)

Fridays, 6-10 PM

Saturdays, 1-5 PM

Child(ren) Lives With:

Mother

Father

Both Parents

Other

Primary Guardian

Name(Required)

First Last

Relationship to Child(ren)(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

Cell Phone Carrier

Please include if you'd like to receive texts from us.

Email(Required)

Secondary Guardian

Name

First Last

Relationship to Child

Address

Street Address Address Line 2 City State ZIP Code

Cell Phone

Cell Phone Carrier

Please include if you'd like to receive texts from us.

Continued Family Information

Child(ren) Name + Age(Required)

Please list full name and age of each child attending NightOWLS, one child per line.

How did you hear about NightOWLS?

Emergency Contact(Required)

First Last

In the event of an emergency, the following person is allowed to pick up my child.

Emergency Contact Relationship to Child(ren)(Required)

Emergency Contact Cell Phone(Required)

Guardian Release Information

I understand that pictures and film my be taken at NightOWLS for the purposes of publicity, pictorial recordings, and identification. I give my permission for my child(ren) to be photographed while at NightOWLS.(Required)

Yes

I will provide all food and drink items for my child(ren) while attending NightOWLS. I understand that the staff cannot provide these items for my child(ren).(Required)

I agree

I disagree

I authorize NightOWLS 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 Signal Pres all pertinent facts about my child’s special needs and accept full responsibility for failure to do so.(Required)

I agree

I disagree

Electronic Signature

I acknowledge that it is my responsibility to notify the NightOWLS Director, in writing, of any changes or revisions to my/our child/children's information contained in the application.(Required)

I agree

Electronic Signature(Required)

Typing your name in this field serves as your signature.

Signature Date(Required)

MM slash DD slash YYYY

Child 1

Child Name(Required)

First Last

Preferred Name/Nickname

Gender(Required)

Male

Female

For females only: Has your daughter had a menstrual period?

Yes

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 disability

Current Medications

Activities my child likes (examples: music, reading, art activities, physical games, independent play)

My child needs encouragement to

My child does NOT enjoy

Please don't ask my child to

My 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 wheel chair

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 Information

Please 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 Others

Communicates 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

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:

I need to register a second child

Yes

Child 2

Child Name	Actions

There are no Entries.

Maximum number of entries reached.

I need to register a third child

Yes

Child 3

Child Name	Actions

There are no Entries.

Maximum number of entries reached.

I need to register a fourth child

Yes

Child 4

Child Name	Actions

There are no Entries.

Maximum number of entries reached.

I need to register a fifth child

Yes

Child 5

Child Name	Actions

There are no Entries.

Maximum number of entries reached.

Name

This field is for validation purposes and should be left unchanged.

NightOWLS has given our son a place where he can be himself in a world that doesn’t always accept him

-NightOWLs Parent

We know you love our son and we really appreciate the attention and care that you have shown him over the years. You guys are truly Christ - like.

– NightOWLS Parent

I just want to let you know that the staff at night owls has always been understanding and kind. I really appreciate you.

– NightOWLS Parent

As Christians, we have a clear call to love others as we would like to be loved. (in fact, how have been loved) Sometimes, it is hard to see how to do that. In NightOwls however, we have a clear path to loving others. It is one of our purest ministry opportunities and has been a blessing to our family.

– Curt C., Volunteer

Sign Up for Embrace Emails

Embrace Ministry Staff

Cara Rock

Director of Embrace Ministry

email | bio

Celestial Allen

Director of NightOWLS

email | bio



Embrace Ministry

For families with exceptional needs

NightOWLS Child Form

Primary Guardian

Secondary Guardian

Continued Family Information

Guardian Release Information

Electronic Signature

Child 1

Allergy Information

Communication with Others

NightOWLS has given our son a place where he can be himself in a world that doesn’t always accept him

We know you love our son and we really appreciate the attention and care that you have shown him over the years. You guys are truly Christ - like.

I just want to let you know that the staff at night owls has always been understanding and kind. I really appreciate you.

Sign Up for Embrace Emails

Embrace Ministry Staff

Cara Rock

Celestial Allen

Volunteer with Embrace Ministry

GET IN TOUCH

612 JAMES BLVD
SIGNAL MOUNTAIN, TN 37377

423.886.2190
info@SIGNALPRES.ORG

OFFICE HOURS
M-F // 8:30 AM-5 PM

STAFF CONTACT INFO

STAY IN TOUCH // SUBSCRIBE

Embrace Ministry

For families with exceptional needs

NightOWLS Child Form

Primary Guardian

Secondary Guardian

Continued Family Information

Guardian Release Information

Electronic Signature

Child 1

Allergy Information

Communication with Others

NightOWLS has given our son a place where he can be himself in a world that doesn’t always accept him

We know you love our son and we really appreciate the attention and care that you have shown him over the years. You guys are truly Christ - like.

I just want to let you know that the staff at night owls has always been understanding and kind. I really appreciate you.

Sign Up for Embrace Emails

Embrace Ministry Staff

Cara Rock

Celestial Allen

Volunteer with Embrace Ministry

GET IN TOUCH

612 JAMES BLVDSIGNAL MOUNTAIN, TN 37377

423.886.2190info@SIGNALPRES.ORG

OFFICE HOURSM-F // 8:30 AM-5 PM

STAFF CONTACT INFO

STAY IN TOUCH // SUBSCRIBE

612 JAMES BLVD
SIGNAL MOUNTAIN, TN 37377

423.886.2190
info@SIGNALPRES.ORG

OFFICE HOURS
M-F // 8:30 AM-5 PM