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Opportunity Details

Access: Intake Profile - Prince William

Ongoing
Prince William
Finances
Group Member

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Additional Information

Please fill out the entire form below with as much detail as possible. Attendee/Participant is the adult or child that will be attending the Access Program. If you need assistance or help with the form please contact Access Ministry at: accessministry@mcleanbible.org
*Gender:
*Date of birth:
*What campus do you attend?
*Access Program(s) interested in(Respite and ADDP require additional registration steps):
Participant Strengths, Skills and Challenges
*Participant diagnosis:
*Particpant's behavioral challenges(Please share any potential behavior challenges so we can be well prepared to care for your child.):
*Participant strengths and interests:
*Behavioral strategies (Please list any strategies that help redirect your child from a challenge behavior.):
Favorite reinforcers:
Participant's communication skills (Please tell us how best to communicate with your child and how they will communicate with us(verbal, signs, non-verbal, etc.)):
Does the participant need help in the restroom?:
Participants Medical and Health Information
Participant allergies(Please include all)::
Participant food allergies/dietary restrictions::
Is an Epi Pen provided?:
Does participant have seizures?:
If the participant has seizures, please include seizure protocol below.
Include: Current frequency, symptoms prior/during seizure, plan for when seizure happens, location of medication
Does the participant need assistance with eating?
If Yes, please be specific on how we should help with feeding or if only caregivers should feed participant.
Participant's mobility needs::
Does the participant have other medical needs we should be aware of?:
Parent/Guardian Info
*Parent/Guardian full name::
Address(if different from child)::
*Phone number::
*Email::
Second Parent/Guardian full name::
Second Parent/Guardian address::
Second Parent/Guardian phone number::
Second Parent/Guardian email::
Sibling names::
*Custody concerns?:
*Emergency contact name::
*Emergency contact phone number::
Photograph Consent
*Do you give permission for your participant to be in photographs and/or in videos in presentations, media releases, newsletters, websites, blogs, social networking sites and other marketing materials for the purposes of sharing news about, and promoting, McLean Bible Church (MBC) and it's Access Ministry programs and services?
Emergency Medical Treatment and Medical Administration Consent
I give permission to the responsible personnel selected by McLean Bible Church to administer medication and other treatment to my child during Access Ministry programs as directed by me in the completed profile form.
I understand that, in the event of a medical emergency, MBC will attempt to contact me, and if MBC cannot immediately reach me, it will attempt to contact all alternate contact person's provided by me. I authorize MBC to administer treatment in accordance with instructions given by such alternate contact person's. If MBC cannot immediately reach either me or any alternate contact person's, in the event of an emergency, I give permission to the responsible personnel selected by MBC to administer/initiate emergency care and to be taken to and treated at the nearest emergency medical facility, as necessary.
Primary Medical Insurance:
Policy Number:
Primary Care Physician Name:
Primary Care Physician Phone Number:
We at McLean Bible Church (“MBC”) look forward to serving you and your child through our Access Ministry programs. MBC seeks to provide a nurturing and safe environment for the care and training of your child during Access Ministry programs. However, no matter how careful our staff and volunteers are, accidents can occur. To make certain that your child is participating in these activities with your full understanding and knowing consent, and informed parental guidance and instruction of your child, we ask that you carefully read this form before submitting. If you have any questions about the program or policies, please contact Julia Lundquist at 703-770-2942. 
In consideration for the services provided by McLean Bible Church (“MBC”) through its Access Ministry programs, I agree to the following terms and conditions of my child’s participation. 
Agreement to Participate and Waiver of Liability. To assist MBC in providing the best care for my child during Access Ministry programs, I agree to provide MBC with accurate and complete medical information about my child, including all special medical, physical, mental, and emotional needs or disabilities that my child may have, on the Access Ministry “Family Profile,” and to immediately update such information as developments occur from time to time. I have read and agree to fully abide by the policies set forth in the Access Ministry “Family Policies & Procedures Handbook” (incorporated herein by reference). 
I understand the risk of injury to my child inherent in a program whose participants consist of individuals with physical, mental, or emotional disabilities, who may exhibit violent or impulsive behavior or suffer from epileptic seizures. During any of Access Ministry’s programs and activities, including but not limited to Sunday School, Respite programs, Camps and family events, my child may engage in activities such as nature hikes, sports activities utilizing balls or other game equipment, contact with animals, amusement equipment rental, and playground equipment, transportation for offsite activities, and outdoor activities resulting in exposure to natural and human-made conditions, such as sharp rocks and glass, unfriendly creatures, and hot sun. If my child participates in Access Ministry’s summer camp program, my child may engage in activities including but not limited to swimming, playing in water parks, and horseback riding. I understand that, while few injuries actually occur, the possible injuries that may occur include, but are not limited to, bruises, cuts, scrapes, broken bones, choking, damage to the head, internal organs, and all parts of the body, drowning, neck and spinal injuries, illness, contagious diseases, other serious injury or death, and impairment to general health and well-being. 
To the extent permitted by law, I (we) assume all risks of injury to my child, including those caused by accidents or by the acts of others. To the extent permitted by law, I (we) further agree to release MBC, Access Ministry, and their staff, volunteers, directors, officers, and agents of all liability for injury or illness to my (our) child or for damage to my (our) child's property arising during any Access Ministry program or event due to any cause except where due solely to the gross negligence or willful misconduct of MBC staff, volunteers, or agents.