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Embrace Information
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Work Entry
Parent/Guardian Information
Campus
Bee Cave
Dripping Springs
Highland Lakes
Southwest
Main Campus
Campus is required.
First Name
First Name is required.
Last Name
Last Name is required.
Email
Email address is not valid
Email is required.
Mobile Phone
Mobile Phone is required.
Birthdate
Jan
Feb
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1914
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1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Birthdate cannot be a future date.
Gender
Male
Female
Gender is required.
Address
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Marital Status
Married
Single
Divorced
Widowed
Separated
Participant Information
Participant's First Name
Participant's First Name is required.
Participant's Last Name
Participant's Last Name is required.
Participant's Date of Birth
Participant's Date of Birth is required.
Please describe the participants needs and diagnosis:
Please describe the participants needs and diagnosis: is required.
Participant communicated by:
Speaking
Sign language
Picture symbols/schedule
Other
Participant communicated by: is required.
Participant enjoys:
Hugs
Singing
Quiet times
Lively activities
Rocking
Story time
Outdoor activities
Arts and crafts
Other
Participant enjoys: is required.
Please describe things that are comforting or calming:
Please describe things that are comforting or calming: is required.
Please describe things that cause distress or should avoid:
Please describe things that cause distress or should avoid: is required.
Please describe favorite toys and activities:
Please describe favorite toys and activities: is required.
Please describe activities and toys that are disliked:
Please describe activities and toys that are disliked: is required.
Please describe current or personal goals:
Toileting:
Wears diapers/Pull-ups
Needs assistance
Toilet training
Independent
Toileting: is required.
Additional toileting information:
Mobility
Needs special support
Crawls
Walks independently
Prone to run
Sits alone
Stands alone
Wheelchair
Mobility is required.
Does the participant have seizures?
No
Yes
Does the participant have seizures? is required.
Favorite snacks:
Favorite snacks: is required.
Food Restrictions/Allergies
None
Milk
Wheat
Other
Food Restrictions/Allergies is required.
Have an Epi Pen?
No
Yes
Have an Epi Pen? is required.
How do you redirect undesirable behavior? What are key phrases that help?
How do you redirect undesirable behavior? What are key phrases that help? is required.
Goals for this year at church:
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