Church Demographic Questionnaire on Disabilities

 Please help your leadership gather information by answering the survey questions about your personal experience with disabilities.  Please return this completed form to your church office.

Definition of a Disability:  According to The Americans with Disabilities Act (ADA) updated in 2010, Disability means, with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities

1.      Do you personally have a disability of any kind?      Yes   No

What would you like your church to know about you and your disability?_____________

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2.      Do you have a child with disabilities?     Yes   No

What would you like your church to know about your child?_______________________

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3.      Do you have someone with a disability in your family?     Yes   No

Parents, Siblings, Extended Family ___________________________________________

How has this impacted your life?______________________________________________

4.      Do you have neighbors that deal with disabilities?    Yes   No

________________________________________________________________________

5.      Do you work with someone who has a disability?    Yes   No

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6.      Are you aware of someone with a disability (intellectual or physical) who might be interested in attending your church?   Yes      No         ________________________________________________________________________

7.      Would you invite a person with disabilities to attend your church?    Yes   No

8.      Would you financially support a disability ministry in your church? Yes   No

9.      Would you volunteer to help with a disability ministry in your church?    Yes   No 

10.    Have you volunteered at any kind of disability event in your community?  Yes   No         _________________________________________________________________________

11.    Do you work professionally with people with disabilities such as social worker, special education teacher, special education aide, therapist, CNA,  caregiver,    management staff, etc. Comments_____________________________________________________________

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12.    Do you have concerns or issues regarding people with disabilities in general? In church?

Comments________________________________________________________________          _________________________________________________________________________