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  • "Getting to Know Me" Assessment

    YMCA of South Florida
  • Date of Birth*
     - -

  • We want to get to know your child better so that we can provide the best possible educational experience while enrolled in our programs.
    No one knows your child better than you. Tell us more about your child.

  • 3. How does your child communicate?*
  • 4. What services does your child currently receive?*
  • 5. Does your child require assistive devices or equipment to access the program activities? (i.e., braces, walker, wheelchair, communication device, insulin, nebulizer or any other device/equipment)*
  • 6. Do you suspect your child has a hearing or vision problem?*
  • 7. Which statement best describes your child's ability to move from one activity to another?*
  • 8. Does your child play/interact best (please check all that apply):*
  • 9. Do any of the following bother your child?*
  • 10. Does your child wander, run away or bolt?*

  • 11. Is your child able to independently do the following activities for him/herself?

  • Use the Restroom*
  • Eat*
  • Walk/Move About*
  • Wash his/her Hands*
  • 12. Does your child take medication?*

  • Individual Assessment

  • What kind of support is needed?*
  • Check behaviors that are a concern*

  • *If behavior management is required. Behaviors may require individualized behavior strategies and/or plan.

  • Medical/Dietary Information

  • Does the participant have seizures?
  • Desired seizure first aid procedures for this participant:*

  • Resources

  • Will anyone visit the participant during our program? Note: This may require additional paperwork processes.*
  • Any other informational or special precautions that would be beneficial to staff
  • Anticipated Start Date:
     - -
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  • THE PARENT/GUARDIAN ACKNOWLEDGMENT BELOW INDICATES AGREEMENT WITH THE FOLLOWING LANGUAGE:

    • I understand this in-take interview is not a guarantee of my child’s placement in the before and /or after school child care program. The purpose of the “Getting to Know Me and Individual Assessment” is to determine if this program is the most appropriate for your child.
    • I understand that this program is not designed for therapeutic or one-on-one care. I understand this before and/or afterschool program operates within the provisions of the American’s Disabilities Act, which provides protection to individuals with disabilities as well as to providers of care for these individuals.
    • I understand and agree that if my child is determined to be a threat to the overall health and safety of him/himself or others, he/she may be expelled from the before and/or after school child care program.
    • I understand that all children regardless of their diagnosis are subject to disciplinary procedures. Parent conferences, probationary periods and suspension are some of the steps that may be taken to ensure children and families are aware there before and/or after school placement is in Jeopardy. In some cases, children may be subject to emergency suspension or expulsion, at the sole discretion of he before/after school program provider, if the child’s behaviors are beyond our staff’s ability to control.
    • I give permission for information from this intake interview to be shared with the before and after school child care Special Needs Committee, if special considerations need to be made for my child’s after school placement.
    • I understand that the information on this form will only be shared with program staff.
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