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The heart of our ministry is to provide a safe and welcoming space. A place where we can help identify and break down barriers that keep people with disabilities and their families from being able to fully participate in the community of church. Every person has a gift to share and all should have access to worship, learn and serve with their church body.
We are so glad you are here!
To better help us find the appropriate supports, please complete the following form as thoroughly as possible. Thank you!
First Name
Last Name
Date of Birth
Grade (if a student)
School (if a student)
Parent Name
Phone Number
Email Address
Parent Name
Phone Number
Email Address
Home Address
Preferred Contact
Voicemail
Text
Email
Emergency Contact - Name/Relationship
Emergency Contact - Phone Number
Siblings Names and Ages
Disability/Diagnosis
Diagnosis in Lay Terms
Medical Concerns
Allergies
Medications
Other
To help us get a better understanding of your child, please check all that apply and expand where necessary. The more information the better!
My child needs assistance with the following:
Eating/Drinking
Toileting
Mobility
Other
Please Explain
Sensory Needs:
Sensitive to Noise/Light
Seeks Pressure
Avoids Certain Textures/Things
Please Explain
Transitions (From Parents, Form Preferred Activity, From Activity to Activity, From Objects) Are:
Easy
Moderate
Difficult
Require More Time/Cues
Please Explain
Communication Ability:
Non-Verbal
ASL
AAC Device
Picture Exchange
Please Explain
Desired Activity:
Music
Reading
Sensory Toys
Water Play
Fidgets
Stuffed Animals
Dolls
Trains
Blocks/Legos
Other
Non-Desired Activities:
Sitting
Music
Movement
Water Play/Sensory Play
Fine Motor
Other
Social Situations in Group Setting Challenges:
Parallel Play
Peer Play
Possessive Over Toys
Personal Space
Easily Over Stimulated
Communicating Needs
Boundaries
Potential Harm to Self
Potential Harm to Others
Inappropriate Touch
Please Explain
Adverse Behaviors:
Refusal to Participate
Hitting
Hair Pulling
Uses Profanity
Throwing Objects
Eloping/Runs Away
Screams/Yells
Crying
Scratching
Harm to Self
Harm to Others
Biting
Please Explain
What do you use for reward or to reinforce good behavior? Please explain.
What do you do to calm or redirect during unwanted behavior? Please explain.
Please provide any additional information that would assist us in caring for your child.
If your child is having a difficult time & is not responding to supports we have in place for them, would you like us to:
Offer Sensory Room
Text Me Immediately
Text Me After 15 minutes
Text Me After 30 minutes
Prefer Not to Be Interrupted
Number to Text
I can be found:
Please type your full name as your digital signature:
Date:
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