Use a survey card in the pew rack or mail to discover disabilities of church members.

Choose a special needs identification card or the more detailed survey form. Before using the card or form, plan how you will use the information. Designate that it will go to a task force or committee equipped to take action on the needs expressed. Remember that for every card signed, there are dozens of unchurched persons in the community with similar needs.

Help our congregation speak love by completing the following survey so that your church can prepare for your family’s special needs.

Special Needs Identification

Indicate the disabilities you or a family member has, for example, Blindness, Visual Impairment, Developmental Delay, Autism, Mobility Impairment, Deafness, Environmental Sensitivity, Chronic Illness etc.

Age and sex of person with disability

List Specific Special Requirements in the Following Categories:

Facilities

Identify needs for facilities that would assist participation. Examples: More handicapped parking spaces, wheelchair ramps, accessible restrooms, special classes, mentors, fume free church plant etc.

(Please turn over to complete.)

Materials

Identify materials needed, for example, large print hymnals, assistive listening devices, etc.

Programs/Services

Identify programs and or services, for example, sign language interpretation, Sunday school programs, mentor or buddy, leisure activities, etc.

Other

(If you wish, you may attach a letter with more details about your needs.)

Age of person with special need_____________

Name _______________________________________ Phone ___________

Address

_________________________________________Zip__________________

Place card in collection plate or leave on the table.  Thank you.

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Or use this more detailed version of the pew card

That all  might be inside

our circle of love to

worship, study and participate

SURVEY OF PERSONS WITH SPECIAL NEEDS

AT _________________________CHURCH

A MEMBER OF OUR FAMILY HAS THE FOLLOWING SPECIAL NEEDS

____Physical

____Mobility impairment (specify)__________________________________

____Have a “handicap” parking permit

____Blind

____Visually Impaired

____Deaf

____Hearing Impaired

____Always at home because of an illness

____Other, please specify___________________________________________

____Emotional

____Intellectual

____Learning  Difference

___Other, please specify  ________________________________________________

___Age and sex of the person with the impairment

____________________________________________________________________

THE FOLLOWING SERVICES WOULD BENEFIT OUR FAMILY:

____A Special Sunday School Class

____Leisure activities   Suggestions:_______________________________________

____Assistance in attending an established Sunday School Class:

____Help with wheelchair

____Help with hearing

____Help with reading

____Transportation

____Mainstreaming of a student and aide care to assist

____Mentor to assist with church activity

____Other

____A special recreation or fellowship group for persons with special needs,

please make suggestions____________________________________________

____Reserved pews or better seating for worship service

____Aids for hearing during worship

____Aids for hearing during Sunday School

____Large-print Materials (Hymnals, Bulletins, Literature)

____Sign language interpretation or closed caption

____Lip-reading classes (speech-reading)

____Better lighting, please specify________________________________________

____Help for persons who cannot leave home

____A scent and fume free worship and classroom environment

____Babysitting for children with disabling conditions

____Fragile care nursery in special environment

____Chronic illness support group

____Caregivers support group

____Caregivers respite plan  Suggestions:__________________________________

____Support groups, please specify________________________________________

____Opportunity to serve my church

____Braille materials or markings in the building

____Help with parking, please specify_____________________________________

____Improved “handicap” parking

____Modify entrances into the building or areas inside the building, please

specify_____________________________________________________________

____Drinking fountains at a lower height

____Telephones at a lower height

____Telephone available near sanctuary for calling metro bus

____Accessible restrooms with facilities for persons with disabilities

____Markings or direction signs for the restrooms for persons with disabilities

____Entry markings directing to “handicap” parking

Yes     No     I wish this information to remain confidential to the task force.

FORM COMPLETED BY ____________________________________________________

Relationship to person requiring services:

____self            ____parent                        ____spouse                        ____child

____friend

____other, please specify________________________________________________

_____I wish a conference with an appropriate person regarding information I have given.

____I would like to help with this new ministry at our church.

____I know a non-church member with a disabling condition who would

benefit from the caring family of our church.

NAME_______________________________________________TELEPHONE_________

ADDRESS________________________________________________________________

Please return this survey to            Accessibility Task Force

Your address

Please write here and on the back of this page any comments or suggestions not previously covered in this survey. Click on this link to download a printable version of a Pew Card.