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Special Needs Visitor Card Date:
1
Name:
Hour : _____
__ Gender: male
9:30
11:00
female
Age: _________
Type of Disability: School:
___ Wheelchair: Yes
No
Most frequently used method of communication (verbalizations, vocalizations, eye gaze, gestures, facial expressions sign language, etc.): _____________________________________________________________ Dietary needs (allergies, favorite foods/drinks ,etc.): ____________________________________________ Acceptable foods/liquids that may be consumed (texture, size ,etc.): ______________________________ Behavioral concerns (challenging behaviors, fears, etc.): ________________________________________ Physical needs (positioning needs, hearing/vision loss, etc.): _____________________________________ Medical conditions (seizures, asthma, diabetes, etc.) ____________________________________________ Toileting needs: ___________________________________________________________________________ Favorite activities: _________________________________________________________________________ Other information: ________________________________________________________________________ _________________________________________________________________________________________
2
Street Address: City, State, Zip: Parent/Guardian: Cell number (please put your phone on vibrate while in the building): E-mail:
3
Names of other siblings of school age and their grade: _______________________
Grade: _______
_______________________
Grade: _______
_______________________
Grade: _______
Allergies/Health Concerns: _________________________________________________________________
Office Use Only: Follow Up ( Phone, Post card )
Status: enrolled, no return, (
)