Parents Name *
Parents Name
Phone *
Address *
Child's Name
Child's Name
Please provide us with information regarding your child’s level of safety awareness in the following situations: crossing the street, responding to ‘stop’, being aware of cars and driveways. What level of support does your child need to be safe in the community (no support; low level – verbal prompts; high level – arm linked with an adult). Do you have concerns about your child’s safety in the community? If yes, please describe.
Please tell us about your child’s favorite toy, game, books, activities. In addition, please tell us anything your child may be sensitive to or dislikes (noise, light, balloons etc.): Additional information you would like to share: