Special Blessings Intake Form If you are human, leave this field blank.Child and Parent InformationChild's name *Child's Age *Please note both age and birthdateParent(s) or guardian(s) name *Phone number *Email * Tell us about your childPlease tell us about any health, learning or behavioral challenges your child faces.Does your child currently have an Individualized Educational Plan (IEP) or 504 Plan in their school setting?If “yes”, please describe the reason, including any diagnoses.Please describe what kind of adaptations or accommodations you think would help your child participate in our programs.For example, would your child benefit from having a one-to-one “Shepherd Buddy” (an adult or mature teen) assigned to work just with him/her in the context of our regular programs?Additional Comments Get in TouchThank you for telling us about your child! Would you like our Special Blessings Coordinator to contact you?Yes, please.No, thank you.Captcha *reCAPTCHA is required.Submit
