Respite Saturday's Registration Form

Respite Saturday's Registration Form

Please use this form to sign up for a Respite Saturday. Please specify your date that are choosing. Please arrive on time, or notify the office if you will be running late. Due to allergies and aversions, we are asking everyone to pack a water bottle, snacks and a sack lunch. If individuals are not allowed to have certain candies during certain activities, please let us know prior to arrival. We highly recommend masks to be worn during events, but do not require. Staff will have masks on at all times. If you are using your waiver services for this event, please list your case manager's name and contact information. We will reach out to your case manager prior to event. We must have the authorization from case manager no later than the Friday prior to event, or unfortunately individual will not be able to attend. To speed the process, we recommend you contact your case manager immediately after confirmation that we have held a spot for your individual. We look forward to seeing to seeing you at one of our Respite Saturdays!
Consumer's Name *

First Name Last Name
Parent/Guardian/Caregiver's Name*

First Name Last Name
Best contact phone number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Case Manager's Name*

First Name Last Name
Case Manager's Email
example@example.com
Case Manager's Phone Number*
Please enter a valid phone number.
Consumer's Medicaid Number (type N/A if not available)*
Service Type for Authorization (NOA)*
You will tell case manager to assign Amiable Home Care Inc. To this service type for billing purposes.
Any Dietary Needs, Restrictions, or Allergies. If no, please type N/A*
Does Consumer display any behaviors? If so please explain behaviors and how you help de-escalate them. If no, please type N/A*
Does Consumer have any physical disabilities or impairments? If no, please type N/A*
You agree to provide, snacks, lunch, water bottle for consumer to help with dietary needs.*
Saturday Events*
PCISP, BSP, etc.

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Parent/Guardian/Caregiver's Signature*

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Today's Date*

MonthDay Year
Date
Please Remember this event is FIRST COME FIRST SERVED! Thank you so much!
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