INFORMATION

Thank you for your interest in participating in Compassionate Heart Ministries Program. Our program is created to foster friendships between volunteers and young people with mild to moderate disabilities. Your answers to the following statements will help us as we consider your request to join our program.

Our mission is to build inclusive relationships in Christ for families and individuals living with mild to moderate disabilities.

Ages 14-45
I understand that CHM has the right to accept or deny the application before or after the interview.*

YesNo
1. Will your son or daughter need medication during program hours?*

YesNo
2. Has your son or daughter ever been tried and/or convicted of a felony?*

YesNo
3. Does your son or daughter need bathroom assistance, regular prompts to use the bathroom and/or have accidents?*

YesNo
STOP! If you have answered yes to questions 1, 2 or 3 unfortunately we are unable to accommodate your son or daughter.

Family Information
Mothers Name

First NameLast Name
Phone Number
Email Address
Fathers Name

First NameLast Name
Phone Number
Email Address
Guardian Name

First NameLast Name
Relationship
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The best contact person/phone number we can reach out to when your son or daughter is at CHM*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Information

The emergency contact must be someone other than the parent/guardian:
Name:*
Relationship:*
Phone/Cell*
Please enter a valid phone number.Format: (000) 000-0000.

Health Information
Do you currently have health insurance?*

YesNo
If yes, please complete the following information:
Primary/Secondary Insurance Company
Subscriber's Name
City
State
Zip
Phone
Policy #
Group #
Does your insurance company require pre-authorization for medical treatment?

YesNo

Group Home Information

(If applicable)
Name of Group Home
Address of Group Home
Contact Person Name
Contact Person Phone #
Please enter a valid phone number.Format: (000) 000-0000.
2nd Contact Person Name
2nd Contact Person Phone #
Please enter a valid phone number.Format: (000) 000-0000.
This is the primary mailing address

YesNo

Family Information