Drop Off Care Packet - PNO and School's Out Camps 2024

We Rock Care - Health & Contact Information
Child's First Name*
Child's Last Name*
Birth Date*

MonthDayYear
Date
Parent/Guardian's Name*
Email*
example@example.com
Phone Number*
Additional Contact
Relationship to Child
Phone Number
Allergies:*

No Known AllergiesFoodMedicineEnvironment (insect stings, heay fever, etcOther
Please explain allergies in more detail:
Restrictions:*

I have reviewed the program and activities of WRTS and feel my child can participate without restrictionsI have reviewed the program and activities of WRTS and feel my child can participate with the following restrictions or adaptations:
Please describe any restrictions in more detail:
Signature (Parent/Guardian)

Clear

Waiver Designation of Caregiver

For Parent/Guardian Only
I, Parent Name am the parent or guardian of Child Name , and we receive services as a private paying client or sponsorship. I hereby designate Ashley & Nathan Green to provide Respite Services to my family. The determination in designating this Caregiver is my sole responsibility, and I waive any and all claims and/or actions against CRR Kids LLC for my decision. Unless revoked, this waiver will remain in effect during my family's service authorization for Respite Services provided by CRR Kids LLC.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

Please list full names for all adults who may pick up your child. It is your responsibility to inform them to bring their state issued ID to pickup.
Does your child have a special needs diagnosis? If yes, please list any behaviors and specific needs. We strive to meet every child's individual needs. You can also list any strategies or practices that you use as family that we can emulate at camp to help your child feel most comfortable.
Please list full names for any adults who will accompany your child to camp (ABA, other therapists, etc)
Should be Empty: