Limitless Disability Ministry | Adult intake | NorthPointe Community Church

Birthday

/ /

Caregiver's Name

Caregiver's Cell Phone

Home Phone

Email

Contact Preference

Call Text Email

Emergency Contact

Food sensitivities/hazards

Other medical or learning issues

I enjoy

I get frustrated when...

Loud Noises Bright Light Darkness Being Touched Talking Hungry I'm Tired People in my Personal Space

You can help me calm down by

Food/Drink Quiet Time Hugs Music Videos Using Technology Talking with someone

Restroom Needs

Independent Diaper Ok - but needs supervision

Diretary Resrtictions

Milk Dyes Nuts Gluten Bottle Tube Feed

Communication

Verbal Non-verbal Sign Language Communication Device

Sensory Needs

Other information (i.e. avoidances, medical considerations, communication needs, intense focus areas, etc.)

Limitless Disability Ministry | Adult intake