Section 1 of 2
"Share Your Story" Form
We are so excited to have you and your children participate in our Belong Ministry! Belong Ministries are ministries and programs at Bethany Community Church that support and connect families of children with special needs, foster families, adoptive families, and any families or children that could use an extra buddy for support. The following questions are intended to help us best care for your kids, to make sure they are happy, healthy, and cared for during their time with us.
Please email Amy Wilkinson at amyw@churchbcc.org for questions. Thank you!
Please email Amy Wilkinson at amyw@churchbcc.org for questions. Thank you!
Email
This form is collecting emails.Change settings
Child's name (first & last):
Child's name (first & last):
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Child's birthday:
Child's birthday:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Parent/Guardian name(s) (first & last):
Parent/Guardian name(s) (first & last):
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Parent/Guardian email(s):
Parent/Guardian email(s):
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Emergency contact name (first & last):
Emergency contact name (first & last):
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Emergency contact phone:
Emergency contact phone:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
We as a team are so excited to have your child here! What are some things we can do to help them feel loved and welcomed?
We as a team are so excited to have your child here! What are some things we can do to help them feel loved and welcomed?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
What are some of your child's favorite activities?
What are some of your child's favorite activities?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Please list any medical and educational diagnoses that would be helpful for our team to know
Please list any medical and educational diagnoses that would be helpful for our team to know
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Please list all medications your child is currently taking, and please take note if any of these medications must be left on site with your child.
Please list all medications your child is currently taking, and please take note if any of these medications must be left on site with your child.
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Please list any allergies your child has:
Please list any allergies your child has:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
What (if any) triggers cause your child to become frustrated or fearful?
What (if any) triggers cause your child to become frustrated or fearful?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
If there is a trigger, what do your child's behaviors look like?
If there is a trigger, what do your child's behaviors look like?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
If your child becomes upset, what are the best coping strategies to help them deescalate?
If your child becomes upset, what are the best coping strategies to help them deescalate?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
What does a successful Sunday morning look like for you and your child? (skip if you do not attend Bethany on Sunday mornings)
What does a successful Sunday morning look like for you and your child? (skip if you do not attend Bethany on Sunday mornings)
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
What language or supports can be used proactively (e.g., common verbiage used at home and school, social stories, visuals, etc.)?
What language or supports can be used proactively (e.g., common verbiage used at home and school, social stories, visuals, etc.)?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Every child is special, what is something unique about your child that will help us understand and connect with them?
Every child is special, what is something unique about your child that will help us understand and connect with them?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Anything else you would like a buddy to your child to know?
Anything else you would like a buddy to your child to know?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Section 2 of 2
Belong Ministry Rhythms & Support
Please fill out the following details to let us know what areas of Belong Ministries you are interested in being involved in.
Belong Ministries provides regular Sunday morning buddies for all children that could use any extra support for Sunday School or other church events. Are you interested in a Sunday Buddy for your child?
Belong Ministries provides regular Sunday morning buddies for all children that could use any extra support for Sunday School or other church events. Are you interested in a Sunday Buddy for your child?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Yes
No
Maybe (I need more information about this first)
We already have a buddy.
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
If so, what service would you prefer?
If so, what service would you prefer?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
9:30am
11am
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
What Belong Ministry events are you interested in receiving regular invitations to?
What Belong Ministry events are you interested in receiving regular invitations to?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Sunday Buddies
Buddy Support for all Bethany events
Mothers of Children with Special Needs Support Group
Fathers of Children with Special Needs Support Group
Foster & Adoption Support Group
Respite Events for children with special needs, fostered children, adopted children, and siblings
Monthly Newsletter with all events and available resources
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Are there other ways your family could use support during this time?
Are there other ways your family could use support during this time?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Link to Sheets
Message for respondents
This form is no longer accepting responses
Summary
Question
Individual
Insights
Total points distribution
Loading...
Settings
Responses
Manage how responses are collected and protected
Presentation
Manage how the form and responses are presented
Defaults
Form defaults
Settings applied to this form and new forms
Question defaults
Settings applied to all new questions