FAMILY REGISTRATION

One form required for each person with special needs

Contact us with questions at specialneeds@loveourcity.com or text 916-390-2900

  • The special needs ministry is available during the 9:00 and 11:00 services. Heroes range in age from 2 years through young adults. To utilize our inclusion program, please contact us in advance.

  • We offer Inclusion Buddies for families registered to attend classes or Bible studies on Wednesday nights. Contact us in advance and we will do our best to provide a Buddy for your child or young adult.

  • Parent's Night Out is a free respite night for families impacted by special needs. Parents bring their children, special needs and siblings, to our Community Center from 6:00pm to 8:30pm for a night of supervised fun activities, food, and refreshments!

  • Shining Stars Prom (ages 16+), Celebrate America, Love Our City Christmas, Back to School Bash.

  • This social/spiritual group for adults 18+ meets on the 2nd Saturday each month in the Destiny Community Center. Enjoy a night of games, worship, bible teachings and prayer.


Family Information

Participant Information

Mother's Information

Father's Information



Please List all Siblings Names and Ages Attending

(required for attendance)

Emergency Contact

(In Case We Cannot Reach You) 

In case of an emergency, the following person may be called and is authorized to pick up my child(ren). Must Be Someone Other Than a Parent.

Positive identification must be provided before the child will be released.


Medical Needs





Communication Needs


Bathroom Needs

*Please have your participant(s) use the restroom prior to drop-off.  Our volunteers and staff can assist children with the restroom if needed, but it is our policy that children over the age of 2 are not to be diapered by volunteers or staff. Parents are called when a bowel movement occurs while not in the restroom. 


  • (Volunteers are not allowed to assist with caterizations).

Feeding Needs




ALLERGIES

Behaviorial Needs


PERMISSION / AUTHORIZATION AGREEMENT

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN INDICATING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE PROVISIONS.
I have fully disclosed to Destiny Church all pertinent facts about my participant's special needs and accept full responsibility for missing information.
I will supply all the required food, drinks, snacks, and diapers/wipes for my participant (if applicable).
In case of an emergency or accident, I understand Emergency Medical Services will be summoned via 911. I authorize EMS attendants to perform any medical treatment, medication or appliance deemed necessary by the EMS attendants. I also authorize transportation by EMS to the nearest appropriate medical facility, as determined by EMS. I understand that I will be responsible for payments of all EMS, hospital, and physician charges for emergency services to my participant.

I have read the above permission/authorization statements and agree to the terms designated in each.

PUBLICITY RELEASE

The respite night event is designed to lessen the stress of families caring for children with special needs. Because we try to reach as many families as possible, we may publicize the program through television, radio, and print media in a positive manner. The use of your name, your child(ren)'s name or picture is voluntary. If you are willing to participate in our effort to help other families learn about the respite night in the future, please check YES below to give us permission.


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