Safe Harbor & Masterpiece Ministry Outreach Registration
Please fill out this registration form for your adult with special needs attending Masterpiece Ministry Outreach.
Name of Parent/Caregiver
*
First Name
Last Name
Email of Parent/Caregiver
*
example@example.com
Cell of Parent/Caregiver
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Parent/Caregiver (2nd)
First Name
Last Name
Email of Parent/Caregiver (2nd)
example@example.com
Cell of Parent/Caregiver (2nd)
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Adult with Special Needs
*
First Name
Last Name
Birthdate
*
What Helps Comfort Your Adult?
*
What Does Your Adult Enjoy Most?
*
What Is Your Adults Favorite Snack and Drink?
*
What Is Your Adults Primary Diagnosis?
*
Any Allergies?
*
Medications?
*
How Can We Best Support Your Adult?
*
Emergency Contact Name and Number
*
Communication Support Needs?
*
Social Interaction Support Needs?
*
Behavior and Regulation Support Needs?
*
Learning and Cognitive Support Needs?
*
Motor Support Needs?
*
Sensory Support Needs?
*
Ability Acknowledgement: I understand that the program provides supervised recreational activities and agree to release the organization from liability except in cases of negligence.
*
Submit
Should be Empty: