Special Requirements Form | Smithfield Baptist Church

Does your child require special attention? Including but not limited to:

Reach out! We'd love to connect to see how we can serve your children best.

Child Special Requirements Form

Date*

Email*

Parent or Guardian's Email

1st Parent or Guardian's Name*

2nd Parent or Guardian's Name

Address*

Phone*

Health Information*

Please list any health issues including allergies your child may have. Enter N/A if non-applicable.

Learning Disabilities*

Please list any learning disabilities including dyslexia, ADHD, etc., your child may have. Please enter N/A if non-applicable.

Child's Interests

List any interests, strengths, or weaknesses.

Other

Are there any circumstances at home that we should be aware of?

Emergency Information*

Who should we contact in case of an emergency other than yourself?

Emergency Phone*( ) -

Emergency Contact's Phone Number

Please leave this field blank.

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