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Joy Group Ministry Participants

JOY Group provides an opportunity for those with cognitive impairment to experience a worship service designed just for them. JOY Group meets from 3-4:30PM on the First and Third Sundays of each month and does not meet on Holiday Sundays. Please note: Photos and/or videos may be captured during Summit Church programming or events and could be posted on our public platforms. If you have any questions, please email info@summitniles.com.

Your name *

Last name

Email address *

Address *

Country

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Phone number

Phone type

Birthdate *

Gender *

Independence Level of Participant *

Check all that apply

Toilet Independently

Feed Self

Follow Directions

Travel Independently

Obey Safety Rules

Other Information

Nature of Impairment *

Check all that apply

Cognitive Impairment

Physical Impairment

Emotional Impairment

Visual Impairment

Hearing Impairment

Other

Needed Accommodations

Walker/Cane

Hearing Aids

Pull-ups or Diapers

Wheelchair

Eye Glasses/Contacts

Other

Behavior Issues

Check all that apply

Biting

Tantrums

Running

Bullying

Scratching

Stealing

Spitting

Vomiting

Hitting/Kicking

Lying

Pinching

Other

Do you have diabetes? *

No

Yes

Behavior interventions that work:

Known Allergies

Special Toileting Needs

Caregiver Information

Caregiver's Name:

Caregiver's Best Phone Number:

Caregiver's Email:

Facebook?

Text Messages?

Emergency Contact Name

Emergency Contact Phone Number

A copy of your responses will be sent to your email address.

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SUMMIT CHURCH
info@summitniles.com
269-683-9245

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