Member Intake Form – Child with Disabilities - URBAN INDIGO

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Member Intake Form – Child with Disabilities

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Section 1: Child Information

* Indicates required field

Full Name of Child *

Preferred Name/Nickname *

Date of Birth *

Gender Identity *

Primary Diagnosis/Disability (if applicable) *

Secondary Diagnosis (if any) *

Current School / Program *

Grade Level / Class Setting *

Section 2: Family Identification & Cultural Background

Race (check all that apply) *

Black or African American White Hispanic or Latino/a/x Asian Native American / Alaska Native Native Hawaiian / Pacific Islander Middle Eastern / North African Multiracial Prefer not to answer

Ethnicity or Cultural Identity (optional) *

Primary Language Spoken at Home *

Secondary Language (if applicable) *

Preferred Language for Communication *

Prefer to self-describe *

Section 3: Parent/Caregiver/Guardian Information
Please list all caregivers in the child’s life who may be involved in programming, communication, or decision-making.

Primary Parent/Caregiver/Guardian

Name *

Relationship to Child *

Phone Number *

Email Address *

Mailing Address *

Secondary Parent/Caregiver/Guardian (if applicable)

Name *

Relationship to Child *

Phone Number *

Email Address *

Housing Status (check any that apply) *

Parent/Guardian Home Foster Care Group Home Homeless / Transitional

Other (please specify) *

How did you hear about Urban Indigo Foundation? *

Section 4: Sibling Information (Optional)

Are there siblings in the household? *

Yes No

Sibling Name Age Disability *

Yes No Not Sure

If yes, please list below: *

Section 5: Insurance & Medical Information

Health Insurance Type (used solely to support your family; no details required) *

Medicaid PeachCare Private Insurance Uninsured

Other (please specify) *

Primary Care Physician Name (optional) *

Seizure History: *

Yes No

If yes, please describe *

Allergies (Food, Medication, Environmental) *

Medications (daily or as-needed) *

Sensory Sensitivities *

Behavior Support Needs (if any) *

Mobility Needs *

Ambulatory Uses Walker Uses Wheelchair

Toileting Needs *

Section 6: Educational & Service History

Areas of Support (check all that apply) *

Speech Therapy Occupational Therapy Physical Therapy ABA / Behavior Therapy Special Education Services Social Skills Support Assistive Technology

Other: *

IEP or 504 Plan in Place? *

Yes No

Is your child currently receiving services outside of school? *

Yes No

If yes, please describe *

Section 7: Releases & Consent

Photo/Video Release:

I grant permission for my child’s photo or video to be used in program promotion, social media, or newsletters. *

Yes No

Emergency Medical Consent:

I authorize Urban Indigo Foundation staff to obtain emergency medical care for my child if I cannot be reached. *

Yes No

Data Consent:

I understand that this information will be kept confidential and used solely to support my family’s needs. *

I agree

Parent/Guardian Signature: *

Date *

Submit

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Phone: 404.353.0432

Home
About Us
Services
Donate Now
Blog
Contact Us
Latest Updates and News
FAQ
Testimonials
Member Intake Form – Child with Disabilities
Request for More Information Form
Fellowship Application
- Photography Archives
- Digital Art Archives

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