Ten Mile Christian - Special Families Interest Form

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

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

Other

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:

SPECIAL FAMILIES INTEREST FORM

To better help us find the appropriate supports, please complete the following form as thoroughly as possible. Thank you!

To help us get a better understanding of your child, please check all that apply and expand where necessary. The more information the better!

Sunday Service Times

Contact Info

Accessibility

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