Congregants with Disabilities Questionnaire

Congregants with Disabilities

We would like to connect with you better!
Note: This questionnaire is 100% OPTIONAL.

We respect your right to privacy. Your membership at Calvary Baptist Church will not be affected if you choose not to complete this form, or if you choose to omit any information, including names and contact info. Even anonymous responses will assist CBC in identifying and meeting the variety of needs in our congregation.
Applicant Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
I am

A child with disabilities (10-17 yrs old)An adult (18-35 yrs old) with disabilitiesAn adult (36+ yrs old) with disabilitiesA parent/guardian of a child with disabilitiesA parent/guardian of an adult with disabilities
Name of the Congregant with Disabilities

First NameLast Name
Describe your/your loved one's disability (check all that apply)

AutismIntellectual disabilityDown SyndromeLearning disabilityADHDDyslexiaTraumatic brain injuryVisual ImparimentHearing ImparimentMental IllnessOCDPhysical disabilityODDTourette's SyndromeOther
How and how much is your/their daily life impacted by your/their disability?
Optional
In the following section, please indicate how useful each of these accessibility aids would be for you or your loved one at CBC.

1 = Unhelpful, would never use

2 = Slightly helpful, would rarely use

3 = Moderately helpful, would use regularly

4 = Highly helpful, would use often

5 = Necessary, required for participation
Visual Aids

1

2

3

4

5

1 is Unhelpful, 5 is Necessary
ASL Interpreter

1

2

3

4

5

1 is Unhelpful, 5 is Necessary
Braille Signage

1

2

3

4

5

1 is Unhelpful, 5 is Necessary
A Sensory-Friendly Room

1

2

3

4

5

1 is Unhelpful, 5 is Necessary
Noise-Reducing Headphones

1

2

3

4

5

1 is Unhelpful, 5 is Necessary
1 on 1 Support

1

2

3

4

5

1 is Unhelpful, 5 is Necessary
Connection with Local Resources and Services

1

2

3

4

5

1 is Unhelpful, 5 is Necessary
What else would help you or your loved one participate in worship, fellowship, and ministry at CBC?
Should be Empty:

Congregants with Disabilities

In the following section, please indicate how useful each of these accessibility aids would be for you or your loved one at CBC.