Child Information Form for Respite Care
Please fill out this form with as much detail as possible to help our respite care team provide your child with the best experience. This form is a work in progress. If you can think of any other information to add to it or questions to ask, please include that in the other information section at the bottom. Please note that we will NOT be able to provide respite care to the following: * Children under the age of 3 * Those not potty trained or who cannot help change themselves. If your child requires additional support in the bathroom, please share that with the Respite Lead through email at info@keepcalmtoolkit.com. * Children requiring medication to be administered during their time at The Zone. (other than pills (in original bottle), inhaler, topical gel, and epi-pen). We are not able to inject medication at this time. Thank you for your understanding, and we can't wait to hang out with your child!
Name of child
*
First Name
Last Name
Does your child have a nickname they like to be called? What is it?
Age of child
*
Child's birthday
Parent Name completing this form.
First Name
Last Name
Parent email
example@example.com
Does your child have CLTS?
Yes
No
If yes: Who is your Case Manager?
First Name
Last Name
Case Managers email
example@example.com
Case Managers phone #
Please enter a valid phone number.
What day(s) of the week are you looking for respie care for?
Saturday
Sunday
Tuesday
Wednesday
Thursday
Friday
What diagnoses (if any) does your child have?
*
Does your child have any allergies? If so, to what?
*
How does your child communicate? Is there anything the respite worker should know about your child's communication? (verbal, written, sign language, talk to text device, AAC device, etc..)
*
Please share with us ways to positively work with your child. What can a respite worker do to ensure your child has a good experience? Does your child have any positive coping skills that they use or like to use?
*
Please share with us ways that the respite worker should not work with or communicate with your child? What does your child NOT like?
*
Will your child need to take any medication while at the Sensory Zone? All medications will need to be in original bottle with full instructions and kept at the front desk during respite.
Yes
No
What type of medication may your child need to take while at the Sensory Zone? All medications will be administered by lead staff on site that day according to instructions provided.
Does your child require assistance with any of the following:
going up or down stairs
putting on or tying their shoes
opening snacks or drinks (provided by parent, no peanut products please)
transitioning from wheelchair to foam pit, trampoline, crash pad or swing)
bathroom assistance (if clicked, please explain below)
If you clicked bathroom assistance, what assistance would they require?
What hobbies or interests does your child have?
*
What room or area of the Sensory Zone does your child LOVE the most? Click all that apply.
*
Gym
Calming Room
Toddler Zone
Touch wall area
Quiet Nook
Game Room
Outside fenced in area
What else would you like the respite worker know about your child?
*
Which of the following can the staff at the Sensory Zone adminster to your child?
ice pack
tylenol (childrens)
basic medical attention (scratches, bumps, bruises)
cough drop
popsicle for sore throat
Other infomation not asked for that you feel is important:
*
Parent #1 Information
First Name
Last Name
Phone Number:
Parent #2 Information
First Name
Last Name
Phone Number:
Emergency Contact person (non guardian to contact in case of an Emergency)
*
First Name
Last Name
Emergency Contact phone #
*
Please enter a valid phone number.
Signature
Submit
Should be Empty: