EPIC Special Needs Taraweeh Respite Care Registration

EPIC Special Needs Taraweeh Respite Care Registration

Respite Care will be offered between 9:00 PM and 11:00 PM every Friday & Saturday. If you would like to utilize this service please complete the form below, read the EPIC Waiver of Liability and sign the form. Jazakomullahu Khairain.
Boys Ages : 4 to 12

Girls: All Ages
Child Name*

FirstLast Name
Child Age *
Boys: 4-12 , Girls: All ages
Parent/Guardian Name*

FirstLast Name
Phone Number*
Email*
example@example.com
Diagnosis *
Gender*

MaleFemale
Special Instructions/Allergies *
Dates Respite Care Needed*

Friday, March 15thSaturday, March 16thFriday, March 22ndSaturday, March 23rdFriday, March 29thSaturday, March 30thFriday, April 5thSaturday, April 6th
WAIVER & RELEASE OF LIABILITY
Signature*

Clear
Should be Empty:

WAIVER & RELEASE OF LIABILITY