Family Application

Family Application
Name
First NameLast Name
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Area CodePhone Number
Your Information
Which Family Retreat would you like to attend
T-shirt Size
Church Name
Primary Language
List any other languages you use for communication other than English.
Is your family bringing a Personal Care Attendant (PCA)?
Name of your PCA
First NameLast Name
Medical Information
Insurance Policy Carrier
Insurance Policy Number
Physician Information
First NameLast Name
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Area CodePhone Number
Additional Notes
What other Family Retreats have you attended?
How did you hear about Joni and Friends?
If other, please tell us how
Your Information
Gender
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Do you have a disability?
What disability do you have?
Do you have any Medical Conditions.
List any medical conditions you have.
Do you require any special accommodations?
Please describe these accommodations.
Do you require medical equipment?
Please describe
Have you been treated for mental health concerns?
What is important for us to know about your disability or medical conditions?
List any medications you take. What happens if you miss your medications?
Do you have any allergies (Seasonal, Medication, Food, etc.)
Please list these allergies and what happens when you have a reaction.
Emergengy Contact Information
Emergency Contact 1
Name
First NameLast Name
Relationship
Email
example@example.com
Phone Number
Area CodePhone Number
Emergency Contact 2
Name
First NameLast Name
Relationship
Email
example@example.com
Phone Number
Area CodePhone Number
Family Consents
Please review the Family Participation Consent for Joni and Friends Family Retreats.
I agree to the Family Participation Consent
Please review Joni and Friends Photo, Video, and Audio Release.
I agree to the Joni and Friends Photo, Video, and Audio Release.
Information Sharing - I give my consent to have my contact information shared with other attendees in the Family Retreat Directory. (*Joni and Friends does not share information with anyone outside of the ministry.)
Financial Agreement - If I am approved to the Outreach, I agree to the Outreach Cost and the fundraising deadlines given and understand that all funds are due one month before the Outreach. I also understand that all funds given to Joni and Friends toward my Outreach costs are non-refundable.
How many additional family members?
- Additional Family Members
- Additonal Family Member 1
- Name
  First NameLast Name
- Date of Birth
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Relationship to primary applicant
- Insurance Carrier same as primary applicant?
- Insurance Carrier
- Insurance Policy Number
- Physician same as primary applicant?
- Physician Information
  First NameLast Name
- 1
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- 2
  Area CodePhone Number
- Additional Family Member T-Shirt Size
- Does this family member have a disability?
- Please Describe
- Does this family member have any medical conditions?
- Please describe
- Does this family member need any special accommodations?
- Please describe
- Does this family member require any medical equipment?
- Please describe
- What is important for us to know about their disability or medical conditions?
- List any medications they take. What happens if they miss their medications?
- Does this family member have any allergies (Seasonal, Medication, Food, etc.) ?
- Describe these allergies and what happens if they have a reaction?
- Has this family member ever been treated for Mental Health concerns?
- Additional comments
- Additional Family Member 2
- Name
  First NameLast Name
- Date of Birth
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Relationship to primary applicant
- Insurance Carrier same as primary applicant?
- Insurance Carrier
- Insurance Policy Number
- Physician same as primary applicant?
- Physician Information
  First NameLast Name
- 3
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- 4
  Area CodePhone Number
- Additional Family Member T-Shirt Size
- Does this family member have a disability?
- Please Describe
- Does this family member have any medical conditions?
- Please describe
- Does this family member need any special accommodations?
- Please describe
- Does this family member require any medical equipment?
- Please describe
- What is important for us to know about their disability or medical conditions?
- List any medications they take. What happens if they miss their medications?
- Does this family member have any allergies (Seasonal, Medication, Food, etc.) ?
- Describe these allergies and what happens if they have a reaction?
- Has this family member ever been treated for Mental Health concerns?
- Additional comments
- Additional Family Member 3
- Name
  First NameLast Name
- Date of Birth
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Relationship to primary applicant
- Insurance Carrier same as primary applicant?
- Insurance Carrier
- Insurance Policy Number
- Physician same as primary applicant?
- Physician Information
  First NameLast Name
- 5
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- 6
  Area CodePhone Number
- Additional Family Member T-Shirt Size
- Does this family member have a disability?
- Please Describe
- Does this family member have any medical conditions?
- Please describe
- Does this family member need any special accommodations?
- Please describe
- Does this family member require any medical equipment?
- Please describe
- What is important for us to know about their disability or medical conditions?
- List any medications they take. What happens if they miss their medications?
- Does this family member have any allergies (Seasonal, Medication, Food, etc.) ?
- Describe these allergies and what happens if they have a reaction?
- Has this family member ever been treated for Mental Health concerns?
- Additional comments
- Additional Family Member 4
- Name
  First NameLast Name
- Date of Birth
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Relationship to primary applicant
- Insurance Carrier same as primary applicant?
- Insurance Carrier
- Insurance Policy Number
- Physician same as primary applicant?
- Physician Information
  First NameLast Name
- 7
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- 8
  Area CodePhone Number
- Additional Family Member T-Shirt Size
- Does this family member have a disability?
- Please Describe
- Does this family member have any medical conditions?
- Please describe
- Does this family member need any special accommodations?
- Please describe
- Does this family member require any medical equipment?
- Please describe
- What is important for us to know about their disability or medical conditions?
- List any medications they take. What happens if they miss their medications?
- Does this family member have any allergies (Seasonal, Medication, Food, etc.) ?
- Describe these allergies and what happens if they have a reaction?
- Has this family member ever been treated for Mental Health concerns?
- Additional comments
- Additional Family Member 5
- Name
  First NameLast Name
- Date of Birth
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Relationship to primary applicant
- Insurance Carrier same as primary applicant?
- Insurance Carrier
- Insurance Policy Number
- Physician same as primary applicant?
- Physician Information
  First NameLast Name
- 9
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- 10
  Area CodePhone Number
- Additional Family Member T-Shirt Size
- Does this family member have a disability?
- Please Describe
- Does this family member have any medical conditions?
- Please describe
- Does this family member need any special accommodations?
- Please describe
- Does this family member require any medical equipment?
- Please describe
- What is important for us to know about their disability or medical conditions?
- List any medications they take. What happens if they miss their medications?
- Does this family member have any allergies (Seasonal, Medication, Food, etc.) ?
- Describe these allergies and what happens if they have a reaction?
- Has this family member ever been treated for Mental Health concerns?
- Additional comments
- Additional Family Member 6
- Name
  First NameLast Name
- Date of Birth
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Relationship to primary applicant
- Insurance Carrier same as primary applicant?
- Insurance Carrier
- Insurance Policy Number
- Physician same as primary applicant?
- Physician Information
  First NameLast Name
- 11
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- 12
  Area CodePhone Number
- Additional Family Member T-Shirt Size
- Does this family member have a disability?
- Please Describe
- Does this family member have any medical conditions?
- Please describe
- Does this family member need any special accommodations?
- Please describe
- Does this family member require any medical equipment?
- Please describe
- What is important for us to know about their disability or medical conditions?
- List any medications they take. What happens if they miss their medications?
- Does this family member have any allergies (Seasonal, Medication, Food, etc.) ?
- Describe these allergies and what happens if they have a reaction?
- Has this family member ever been treated for Mental Health concerns?
- Additional comments
- Additional Family Member 7
- Name
  First NameLast Name
- Date of Birth
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Relationship to primary applicant
- Insurance Carrier same as primary applicant?
- Insurance Carrier
- Insurance Policy Number
- Physician same as primary applicant?
- Physician Information
  First NameLast Name
- 13
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- 14
  Area CodePhone Number
- Additional Family Member T-Shirt Size
- Does this family member have a disability?
- Please Describe
- Does this family member have any medical conditions?
- Please describe
- Does this family member need any special accommodations?
- Please describe
- Does this family member require any medical equipment?
- Please describe
- What is important for us to know about their disability or medical conditions?
- List any medications they take. What happens if they miss their medications?
- Does this family member have any allergies (Seasonal, Medication, Food, etc.) ?
- Describe these allergies and what happens if they have a reaction?
- Has this family member ever been treated for Mental Health concerns?
- Additional comments
- Additional Family Member 8
- Name
  First NameLast Name
- Date of Birth
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Relationship to primary applicant
- Insurance Carrier same as primary applicant?
- Insurance Carrier
- Insurance Policy Number
- Physician same as primary applicant?
- Physician Information
  First NameLast Name
- 15
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- 16
  Area CodePhone Number
- Additional Family Member T-Shirt Size
- Does this family member have a disability?
- Please Describe
- Does this family member have any medical conditions?
- Please describe
- Does this family member need any special accommodations?
- Please describe
- Does this family member require any medical equipment?
- Please describe
- What is important for us to know about their disability or medical conditions?
- List any medications they take. What happens if they miss their medications?
- Does this family member have any allergies (Seasonal, Medication, Food, etc.) ?
- Describe these allergies and what happens if they have a reaction?
- Has this family member ever been treated for Mental Health concerns?
- Additional comments
- Additional Family Member 9
- Name
  First NameLast Name
- Date of Birth
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Relationship to primary applicant
- Insurance Carrier same as primary applicant?
- Insurance Carrier
- Insurance Policy Number
- Physician same as primary applicant?
- Physician Information
  First NameLast Name
- 17
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- 18
  Area CodePhone Number
- Additional Family Member T-Shirt Size
- Does this family member have a disability?
- Please Describe
- Does this family member have any medical conditions?
- Please describe
- Does this family member need any special accommodations?
- Please describe
- Does this family member require any medical equipment?
- Please describe
- What is important for us to know about their disability or medical conditions?
- List any medications they take. What happens if they miss their medications?
- Does this family member have any allergies (Seasonal, Medication, Food, etc.) ?
- Describe these allergies and what happens if they have a reaction?
- Has this family member ever been treated for Mental Health concerns?
- Additional comments
- Should be Empty:

Family Application

Family Consents

Additional Family Members