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:
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.)
Identify materials needed, for example, large print hymnals, assistive listening devices, etc.
Identify programs and or services, for example, sign language interpretation, Sunday school programs, mentor or buddy, leisure activities, etc.
(If you wish, you may attach a letter with more details about your needs.)
Age of person with special need_____________
Name _______________________________________ Phone ___________
Place card in collection plate or leave on the table. Thank you.
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
A MEMBER OF OUR FAMILY HAS THE FOLLOWING SPECIAL NEEDS
____Mobility impairment (specify)__________________________________
____Have a “handicap” parking permit
____Always at home because of an illness
____Other, please specify___________________________________________
___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
____Mainstreaming of a student and aide care to assist
____Mentor to assist with church activity
____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
____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
____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.
Please return this survey to Accessibility Task Force
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.