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?