Child Information Form
Please complete all of the following items:
Sign in to Google to save your progress. Learn more
Email *
Caregiver Name (First) *
Caregiver Name (Last) *
Secondary Caregiver (if applicable)  (First and Last Name) 
Child's Name (First) *
Child's Name (Last) *
Nickname or preferred name (if applicable)
Pronouns - It's important for us to use the desired pronouns with your kids. Please help us by completing below. *
Required
Status *
Length of time in your care (if not biological child) (Please indicate whether in months or years) *
Child's Age *
Date of Birth *
MM
/
DD
/
YYYY
Does the child speak Spanish? *
Child's Ethnicity *
Child's Race (check all that apply) *
Required
CHILD HISTORY & BEHAVIORAL INFORMATION
Please update Kids at Heart staff if changes occur after completing this form.
Child's History (check all that apply or check N/A) *
Required
Comments
Any related diagnoses or disabilities?
Indicate any behaviors or conditions below that the Kids at Heart staff should know about (check all that apply or check N/A): *
Required
How might this impact functioning at Kids at Heart events?
Are there specific things that will trigger certain behaviors with this child? If yes, please explain.     *
How does this child like to be comforted? *
Does this child engage in inappropriate behavior to get attention?  If yes, please describe. *
If yes, please explain
Does your child have inappropriate sexual behaviors? *
Are there any concerns about sexual behavior or issues? Explain.
Are there any special social/public guidelines to be aware of and enforce? Explain.
Should the child be separated from any siblings? If applicable, please explain below. *
Should the child be separated from any other Kids at Heart participant(s)? If applicable, please explain below. *
If the child needs (or may need) to be separated from a sibling(s) or other participant(s), please explain here.
MEDICAL & HEALTH INFORMATION
Please update Kids at Heart staff if changes occur after completing this form.
Health conditions or concerns (check all that apply or check N/A): *
Required
How might the above indicated health concerns or conditions show up at Kids at Heart events? If applicable, please describe.
Any allergies? *
If yes, explain. Please also list any special food/dietary needs or restrictions.
Any additional information that may be pertinent to this child's successful participation in Kids at Heart events? If so, please describe.
SIGNATURE
By signing below, you agree that the information provided in this form is accurate to the best of your knowledge. Please update the Kids at Heart staff if something changes that will impact our ability to provide a safe, healthy, and pleasant environment for the child while in our care.
Signature of Legal Guardian / Parent / Foster Parent (type your name) *
Date of signature *
MM
/
DD
/
YYYY
KIDS AT HEART CHILD INFORMATION FORM
Last updated 09/2022.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Kids @ Heart. Report Abuse
Google Forms