Able Life Ministry Registration

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Form Entry

Able Life is our special needs ministry here at Living Word. We meet Sunday mornings at 9:30 and 11:00 am. We are excited to meet you and your family and to get to know you more. Once you have submitted this form, you will hear from the Able Life Lead. If you have any questions, please contact Cassie Stroman at 717.755.0089 x 107 or by email at cstroman@lwccyork.com.

First Name

First Name cannot contain special characters such as quotes, parentheses, etc.First Name cannot contain emojis or special fonts.

First Name is required.

Last Name

Last Name cannot contain special characters such as quotes, parentheses, etc.Last Name cannot contain emojis or special fonts.

Last Name is required.

Email

Email address is not valid

Email is required.

Mobile Phone

Mobile Phone is required.

Gender

Male Female

Gender is required.

Address

Participant's First Name

Participant's First Name is required.

Participant's Last Name

Participant's Last Name is required.

Participant's Date of Birth

Participant's Date of Birth is required.

Participant's Gender

Please list any specific needs and/or diagnosis the participant has (i.e. learning disability, diabetes, Autism, etc.).

Please list any specific needs and/or diagnosis the participant has (i.e. learning disability, diabetes, Autism, etc.). is required.

Please list any allergies the participant has that we should be aware of.

Please list any allergies the participant has that we should be aware of. is required.

Please list any items and/or activities the participant enjoys and that brings comfort to them (i.e. swinging, a specific toy, a blanket, etc.).

Please list any items and/or activities the participant enjoys and that brings comfort to them (i.e. swinging, a specific toy, a blanket, etc.). is required.

Please list anything that is known to be upsetting to the participant (i.e. transitions, loud noises, touch, etc.).

Please list anything that is known to be upsetting to the participant (i.e. transitions, loud noises, touch, etc.). is required.

How does the participant communicate?

Predominantly Verbal

Sign Language

Gestures

Picture Exchange (PECS)

iPad/Electronic Device

Other

How does the participant communicate? is required.

What bathroom needs does the participant have?

Goes to the bathroom independently

Needs minimal assistance in the bathroom

In the process of potty training

Wears diaper/pull-up

What bathroom needs does the participant have? is required.

What level of support does the participant need?

Needs to be in the Able Life Room for the entire service

Part of service in Able Life and part in Kid Life classroom

Needs a buddy to accompany to Kid Life classroom

What level of support does the participant need? is required.

Submit

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