Special Needs - Getting to Know You

It is a joy to serve children, teens, and young adults with a variety of special needs. Please know that our heart is for every individual to be supported to know Jesus.

As a next step, please complete the form below on behalf of your participant with as much detail as possible. This allows us to provide the best experience and safest environment for everyone involved in the ministry. Once completed, someone from our team will contact you to arrange details of your first visit.

Your name *

Email address *

Phone number *

Birthdate *

Gender *

Address *

Parent/Guardian Information

Primary Parent/Guardian Name *

Primary Parent/Guardian Phone Number *

Primary Parent/Guardian Email *

Second Parent/Guardian Name

Second Parent/Guardian Phone Number

Second Parent/Guardian Email

Emergency Contact Information

Emergency Contact *

Emergency Phone Number *

Which program(s) are you interested in? Please select all that apply. *

Mission Buddies Ministry - Sunday Morning at 11:30 AM (Kindergarten-6th grade)

Young Adult Ministry - Wednesday Nights at 6:30 PM (ages 18-29)

Grade

Does your child receive special services? *

Please list all known allergies and health concerns. *

What is your participant's identified diagnosis (educational or medical)? Please provide a brief description. *

Describe your participant's past experiences (positive or negative) with church. *

Does your participant require assistance with eating/drinking, and/or using the restroom? *

What activities does your participant enjoy? *

What activities seem to be more challenging/difficult? *

What things cause your participant to be afraid or unsettled? Please describe. *

Does your participant have any behaviors that might be harmful or disruptive to him/herself or others? *

What physical or behavioral supports are most beneficial for your participant? *

Is there any additional information you would like us to know?

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