New Participant Registration Form

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Welcome! We're glad you're interested in Reality Ministries. If you have a diagnosed disability or you love someone who does, this is the right place to be!

If you have any questions about this form or the new participant process, you can reach out to Alisa Ginyard, our Outreach Coordinator at alisa@realityministries.org or 919-688-7776.

Participant First Name *

Participant Last Name *

Participant Date of Birth *

YYYY

Does Participant Live *

Independently

With Family

In a Group Home

Other:

Participant's Current Address *

Participant's Home Phone *

Write the number in the format xxx-xxx-xxxx

Participant's Cell Phone *

Write the number in the format xxx-xxx-xxxx

Participant's Email Address *

Participant's Legal Guardian (if different than Participant) *

Guardian's Phone Number(s) *

Write the number in the format xxx-xxx-xxxx

Guardian's email *

Guardian's Address *

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