Empower All Intake Form

Our goal is to create an environment where everyone, regardless of ability, feels welcomed, valued, and fully included in the life of our church community. We currently offer a buddy program and separate settings classroom at the 11:45 AM service.

Together, we can build a more inclusive church where everyone can thrive in their faith journey.
We look forward to seeing how God will use this ministry to bless our church family.

These questions allow us to provide the best experience and safest environment for all of our friends within the ministry. Our church leaders and ministry volunteers will respect your family's right to privacy. Any information shared is communicated directly with those caring for your family member and only on a "need to know" basis. If you have any questions, please contact Emily Usukhbayar at emilyu@lifepointecc.com for more information. Please fill out the participant's information below.

Your name *

Email address *

Birthdate *

Participant's Disability Area: (eg: Down Syndrome, CP, Autism, TBI, Cognitive Delays, etc) *

Allergies: *

Medical Conditions: (eg: Seizures, Diabetes, Asthma, etc) *

Would your child best benefit from being paired up with a buddy or a self-contained environment for small group time?

Please describe your child's understanding and relationship with God:

Likes or Interests: (eg: Music, Art, Sports, etc) *

Dislikes or Triggers: (eg: Loud Noises, Strong Smells, Being Touched/Hugged, Certain Textures, etc) *

Calming Techniques: *

Is there any history of wandering or elopement? *

Any Diapering/Toileting Needs? *

Classroom Situation you wish to be contacted about: *

We may use sensory items in our spaces, please let us know if there is something that this child should not be given (eg: fidgets, weighted blankets, headphones, etc) *

Any additional information we need to know about the participant? *

Parent/Caregiver Information

Parent or Caregiver Email: *

Parent or Caregiver Contact: *

Names, Relationship, and Phone Number

Do you currently attend Lifepointe?

Emergency Contact: *

Name, Relationship, and Phone Number

Check this box if you would like to attend a mock-Sunday service with your child

We would love for you to see what we do on a regular Sunday in our new ministry. This mock-Sunday service will allow you to do that , along with allow us to answer any questions you may have.

Photography permission

Please check this box to grant Lifepointe Church and Lifepointe Kids’ Ministry permission to use your child’s likeness in a photograph, video, or other digital media in any and all publications, including web-based publications, without payment or other consideration.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.