To best serve the needs of people in our community we request that you complete the following
survey for you and your child. All answers are optional.....All information is confidential and will
not be given to third parties.
If you prefer, a printable version of this survey is available(69.5KB)     here.To open this link you
need Adobe Reader.
I feel I may be interested in the mission of Higher Rock Ministries because:
I am Interested in the following: (check the appropriate boxes)
Participating in a Christian Parent or Advocate Organization.
Attending special worship services for people with disabilities
Participating in a disability ministry in my home church
Attend workshops for parenting children with disabilities
Pursuing a Christian alternative for residential placement
click "submit" button only once


My Home Church is:
Address of Church:
Phone no. of Church:
Someone in my family has a disability. 1st Name
 Age:
The Nature of the disability:
Assisting with a Saturday Recreation Program
Receiving Family Counseling
Learn about benefits and program opportunities
Other interests to help us expand our vision:
Your email address
Your First Name:
Your Last Name:
Your Mailing Address:
Your Phone Number: