PCCLift Physical Support Plan | Perinton Community Church

PCCLift Small Group Physical Support Plan

In order to best serve your child with special needs please complete the following questions. Please complete a separate plan for each of your children that has physical needs. This information will be kept confidential.

Today's date

Parents' first and last names

Child's name

Child's age

Please provide a brief description of your child's strengths and interests.

Does your child need 1:1 support?

Yes, we will provide 1:1 support via family or friend

Yes, we need PCC to provide 1:1 support

I'm not sure

If you are providing 1:1 support please list the person's name and relationship to the child.

How does your child communicate best?

Verbally

Non-verbally

Depends on the situation

If your child is unable to communicate verbally, please explain how we can best help your child communicate.

For example, using a communication board that allows your child to point to pictures of emotions or needs.

Does your child use any of the following assistive or adaptive tools?

Check all that apply.

Wheelchair

Scooter

Crutches

Walker

Feeding tube

Oxygen

Prosthetic limb or appendage

Hearing aid or Cochlear Implants

Cane eyestick

Walking stick

Braille mobile phone apps

Mobile phone app to assist with hearing

Other (please list below)

If you selected "other" above please list additional assistive or adaptive tools your child uses.

Will your child need access to food and drink during the group?

We do not provide snacks during the group. However, if your child requires access to food you are welcome to take your child to another room for a snack.

Does your child require toileting support?

We are not able to provide toileting support. However, we will contact you if any needs arise.

Does your child have allergies or additional medical needs? If so, what are they?

Please share any additional information you believe will help us meet your child's needs and ensure he/she has a positive experience.

Thank you for completing the Physical Support Plan. This information will be used to ensure the safety of your child.

Solve 7 + 7 = ?

Service Information:

Bible Classes: 9:15-10:15am

Worship Service: 10:30am - 11:45am

Perinton Community Church

636 High Street Extension

Fairport, NY 14450

585-223-7494

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