Buddy Request Form

If you would like to request a Buddy during church services for yourself or a loved one, please fill out this form. On this form, the ‘Friend’ is the person who will be paired with a Buddy. Someone will contact you soon regarding your form.

Your name *

Email address *

Friend's Information

Name (First and Last) *

Date of Birth *

Parent/Guardian Name *

Parent/Guardian Phone Number *

Emergency Contact Name and Phone Number *

Friend's Support Needs

Are there any diagnoses or areas of need you'd like us to be aware of?

What kind of support would be most helpful during church services? (We encourage participation in age-appropriate services when possible.)

Check all that apply.

Sitting together during age-appropriate service (kids church, preschool, etc.)

Help with transitions (moving between rooms, activities, etc.)

Assistance with communication

Sensory support (removing to sensory room when needed)

Extra encouragement or behavioral support

Physical support (wheelchair, etc.)

Other

Friend's Strengths and Interests

What are some things he/she enjoys?

What helps him/her feel comfortable in new situations?

Friend's Challenges & Calming Strategies

Are there any triggers or situations that may be difficult?

What usually helps if he/she feels upset or overwhelmed?

Friend's Safety & Medical Information

Allergies:

Medical conditions or medications we should know about:

Any safety concerns (wandering, medical alerts, etc.):

Additional Information

Additional information to help the Buddy prepare:

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