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Ministry of Inclusion
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Ministry of Inclusion Request for a Buddy
Ministry of Inclusion: Request for a Buddy
*
Required
First and last name of person completing form
*
Email address
*
Student's name
*
Birthdate
*
Parent/caregiver's name(s)
*
Address (include city, state, zip)
*
Home phone
*
Cell phone
Sibling name(s) and age(s)
School child attends
Grade
Description of special needs including diagnosis (if relevant)
What can we do to help your child be successful?
What are your child’s strengths and weaknesses?
Activities most enjoyed (indoor and outdoor)
Is your child on medication?
Yes
No
If yes, what type of medication?
Seizures
Hearing aids
Allergies
Surgeries
Other things you need to know about my child’s health
Fears
Name three things that motivate your child
What upsets or frustrates your child?
Assistance needed with eating/drinking?
Is help needed for personal hygiene?
Parents would like communication through
Any additional information we should be aware of?