Intake Form
Section 1: Basic Information
Name and Title *
Your answer
Name of Institution *
Your answer
Type of Institution *
Your answer
Number of People Served by the Institution *
Your answer
Address *
Your answer
Phone Number *
Your answer
E-mail Address *
Your answer
Mission Statement *
Your answer
Section 2: Accessibility
Complete this section by selecting one response per question. You will have a chance to add notes at the end of the form.
Parking spaces are specifically alloted for people with disabilities and for easy drop-off/pick-up for children with special needs *
All of the doors in our building comply to ADA standard guidelines, allowing people in wheelchairs or other motor-assistive devices to comfortably enter and leave the space. *
Direction signs and announcements are accessible to all. (Written signs are in large font with contrasting colors and have braille available; verbal announcements are made loudly and clearly; fire alarms use both sound and light notifications.) *
Restrooms are fully accessible including doorways, toilets, sinks, trash cans, and paper towels. *
Mezuzot are placed at low levels for easy access. *
There are railings to hold in hallways. *
Direction signs indicate where the nearest elevator and/or ramp is. *
People with physical disabilities are able to get onto and off of the bima. *
Large print text is available for all materials that the general population uses (books, songsheets, siddurim/prayer books, notices, etc.) *
Any text or announcement made in Hebrew is also made in English. *
Unscented soap, lotion, and cleaning materials are consistently used. *
Sign language interpretation is made available when requested. *
Ritual items are made available to all and placed at levels that people with various abilities can reach and utilize (kippot, tallitot, Torah) *
Section 3: Current Culture
Please answer the questions below as completely as possible
What brought you to Rosh Pina? *
Your answer
What does the word INCLUSION mean to you? *
Your answer
What would inclusion look like at your institution? *
Your answer
What makes your institution inclusive? Who is included? *
Your answer
What makes your institution UNinclusive? Who is NOT included? *
Your answer
What have you done thus far to make your institution inclusive? *
Your answer
What are two things you'd like to do to make your institution more inclusive? *
Your answer
Section 4: Leadership Team
To promote the success of your project we suggest identifying a Leadership Team to help guide the process. This team should have at least three people and should include a synagogue leader (President/Director), a member of the clergy, one educator and one lay leader.
Name and Title of Synagogue Leader
Your answer
Name and Title of Clergy
Your answer
Name and Title of Educator
Your answer
Name and Title of Lay Leader
Your answer
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