Today's Date
MM
DD
YYYY
Name of Child
*
First Name
Last Name
Age
Gender
*
Birthday
MM
DD
YYYY
Name of Parents or Legal Guardians
First Name
Last Name
First Name
Last Name
Parent's/Legal Guardian's Phone Number
(###)
###
####
Parent's/Legal Guardian's Email Address
Parent's/Legal Guardian's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent's/Legal Guardian's County
Is Child's Primary Residence the same as Parents/Legal Guardian?
If Yes, do Parents/Legal Guardians OWN this home?
If No, what % of time do they spend at this address?
List secondary address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Are there other EXTENDED FAMILY members who live in the home?
Is the child an American citizen?
If in the process, explain the timeline for citizenship:
Does the child have siblings?
Do the siblings live with the child?
List Names, Gender, and Age of siblings that live with the child:
Does the child attend school?
Name of School
Name of Child's Teacher
What grade equivalent is the child in?
Does the child have developmental delays or learning disabilities?
Does the child have an IEP (Individualized Education Plan)?
Is the child in a CDC classroom?
Do the siblings attend the same school?
If no, please list the schools of each sibling:
Does your family have health/medical insurance?
Is insurance provided by mother's, father's, or guardian's job?
Is insurance provided by the State of Tennessee?
Does your child require services, such as therapy, that insurance does NOT cover?
If yes, please list the services:
Does the child talk?
Can the child eat regular solid food?
Please list any dietary restrictions:
Can the child fed himself?
Can the child walk on his own?
Is the child in a wheelchair?
If yes, permanently or part-time?
Does the child use a walker?
Can the child sit up and balance himself on his own?
Does the child require 24/7 care from a nurse or professional outside the home?
If yes, are they reliable to show up?
Can the child potty on his own?
Does the child wear diapers for medical reasons?
Does the child's body temperature have to remain constant (or close)?
Do you experience the physical difficulty of lifting your child into bathtub, onto potty?
Do you see a chiropractor for back/neck pain?
Are you able to easily transfer your child to/from bed?
If yes, how do you currently achieve this?
Are you able to easily transfer your child to/from the car?
Do you have a vehicle that is handicap accessible?
Describe your most challenging DAILY STRUGGLES in caring for your child:
Are there things that would make it easier for you to care for your child on a daily basis, If so please explain:
If the child is in a wheelchair or walker, can they get through the door of the bathroom?
Can the child get into the bathtub on their own?
Can the child move freely about their bedroom?
Is your home handicap accessible?
Do you need a handicap ramp to get the child into the house?
Does your child have access that would allow them to get out of their bedroom in case of emergency?
Would wider doorways be helpful to increase child’s mobility inside the home?
Would your home require some renovation/construction in order to achieve handicap accessibility?
Do you have working smoke detectors in your home?
Do you have working carbon monoxide detectors in your home?
What are your child's favorite colors?
Are there colors they strongly dislike?
Does the child have sensory/tactile issues?
If yes, please explain:
What are your child's favorite hobbies?
What are your child's favorite toys/games?
What technology does your child have?
Is there technology that would help your child that you currently do not have or cannot afford to purchase?
If your child could spend one day anywhere or with anyone (real or fictitious), where would it be and with whom?
Is there anything else you would like us to know about your child? If so, please explain below.
How did you learn about KDM?
Who made you aware of this referral process and suggested you apply?
If your child is chosen, are you willing to accept KDM's Free Gift of Love, knowing that it is a Christian Ministry and there will likely be prayer conducted inside your home?
