Special Abilities Intake Form

Name of Child *

First

Last

Child's Age

Child's Date of Birth

Parent/Guardian Name *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Best time to contact you:

Morning
Afternoon (before 5pm)
Evening (after 5pm)

Best time to schedule child's evaluation:

Morning
Afternoon (before 5pm)
Evening (after 5pm)

How did you hear about our program?

What is your child's specific diagnosis?

Does your child have IEP?

Yes
No

What is child's functional level?

High Functioning
Moderate
Low Functioning

Does your child need assistance with any of the following?

Walking
Remaining with a group
Grasping/manipulating objects
Toileting
Listening/following directions
Other

How does your child communicate?

Verbal
Non-verbal

If your child is non-verbal, what form of communication is used?

Describe any special medical needs or allergies that we should know about. *

Are there any special accommodations necessary for physical disabilities?

Has your child participated in any other recreational activities?

Yes
No

If yes, please list activities:

What are your goals for your child in our program?

How would you describe your child’s personality?

Is there anything else that you would like to share about your child?

Schafer Sports Center

5 Graphics Drive,
Ewing Township, NJ 08628
(609) 393-5855
info@schafersports.com
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Special Abilities Intake Form

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