Parent/Caregiver Preliminary Questionnaire We would love to be able to serve you specifically upon your very first visiting Sunday. To do this most efficiently, please fill out this form and tell us a little about your family. All responses are kept confidential. After submitting this form, one of our committee members will contact you and discuss more specifically how we can meet your needs by serving your family while at Hope Church. Tell us about you:Parent/Caregiver Name* First Last Home PhoneCell Phone*Email* Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you currently attend another church?YesNoIf so, may we ask where?How do they serve you and your family member?Tell us about the potential Hope Springs Ministry recipient:Name* First Last Date of Birth Date Format: MM slash DD slash YYYY Developmental/Functioning Age in years:Does this person attend school?YesNoIf yes, where does he/she attend?Is he/she mainstreamed?Grade placement?Specific NeedsOur Hope Springs volunteers are not certified medical professionals. Therefore, it is important for us to make sure we can accommodate your family member’s needs. Specific information below will allow us to serve as best we can.Please check any and all that apply and make specific notes in the box that appears for each: Medical Physical Developmental Emotional Medical:Physical:Developmental:Emotional:Does the participant have a diagnosis?YesNoIf so, what is it?Is there anything else you want us to know in order to serve you while you are at Hope?