Special Needs Intake Form

Name of Person Completing the Form

Relationship to Person with Special Needs (Please answer if completing this form on behalf of someone else.)

This address will receive a confirmation email

Phone

Name of Person with Special Needs (Please answer if completing this form on behalf of someone else.)

Age of Person with Special Needs

Child Between Ages 0-3 Child Between Ages 3-6 Child Between Grades K5-5 Youth Between Grades 6-12 Adult

Gender of Person with Special Needs

Male Female

Description

We desire to be a church in which people of all types and abilities feel welcome and comfortable to worship. If you, a friend, or family member should require special accommodations in order to participate in church activities, please complete the form to the right.

Special Needs Intake Form

Description

Please Fix the Following