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CROSSabilities Family Registration

Please take a moment to compete this form so that we are able to best serve your family.

Your name *

Last name

Email address *

Service time planning to attend *

Primary Adult

First Name: *

Last Name: *

Gender *

Birthdate *

Phone number *

Phone type

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Household members

Child 1 Additional Information

First Name of Child *

Medical Diagnosis *

Please list any medical diagnosis your child has received.

Special Needs Diagnosis *

Please select any special need diagnosis your child has received.

Autism

Down syndrome

Cerebral Palsy

Intellectual Disability

Physical Disability

Other

Does your child receive any services inside or outside of school? *

Does your child have seizures? *

What are your child's toileting needs? *

Is there anything that you know your child might find calming or comforting if needed? *

Is there any information you would find helpful for us to know about you or your child for the first Sunday? *

Is there anything that might be upsetting to your child or are there any behaviors that we should be aware of? *

Child 2 Additional Information

First Name of Child

Medical Diagnosis

Please list any medical diagnosis your child has received.

Special Needs Diagnosis

Please select any special need diagnosis your child has received.

Autism

Down syndrome

Cerebral Palsy

Intellectual Disability

Physical Disability

Other

Does your child receive any services inside or outside of school?

Does your child have seizures?

What are your child's toileting needs?

Is there anything that you know your child might find calming or comforting if needed?

Is there any information you would find helpful for us to know about you or your child for the first Sunday?

Is there anything that might be upsetting to your child or are there any behaviors that we should be aware of?

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Cross Community Church
info@crosscommunity.org
8436056231

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