Thrive Profile

Please fill out this form and click submit.
Your child's information

 
 
 
 
 
 
Diagnosis: Please check all that apply & select degree of severity:

Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Please select one option.
 
 
 
 
Please select all that apply.
 
 
Communication needs

Please select one option.
Please select all that apply.
Please select all that apply.
 
 
 
 
Please select one option.
 
Please select one option.
 
Please select one option.
Please select all that apply.
 
Dietary/feeding needs

 
 
 
 
 
 
 
 
 
 
 
 
Please select all that apply.
 
 
 
 
Medication/Medical Information:

**If you have a medical plan of care for emergencies, please attach a copyThe same plan that you have for school or daycare provider is acceptable. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please select all that apply.
*Behavior Management:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Parent & contact information

 
 
 
 
 
 
 
 
 
Please select all that apply.
***Please update this plan of care yearly or if any significant changes occur in your childs (childrens) status. 
By submitting this form and registering your child for an event at Liberty Church Marietta, you are agreeing to allow Liberty Church Marietta to take photos of your child to be used in future publications for Liberty Church Marietta. I also understand that the program has activities that can possibly involve physical contact with other participants, the ground or equipment, and understand there is a small risk of injuries. I therefore release and discharge all liability for any harm suffered due to my child's participation in the program. I give permission to the staff and volunteers to administer first aid or seek medical care for my child during my child's attendance, if necessary.
 
 

Description

Please fill out this form and click submit.