Child Information Form for Respite Care

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.
Parent Name completing this form.

First NameLast Name
Parent email
example@example.com
Parent's phone Number:
Name of child*

First NameLast Name
Does your child have a nickname they like to be called? What is it?
Age of child*
Child's birthday
Does your child have CLTS?

YesNo
If yes: Who is your Case Manager?

First NameLast Name
Case Managers email
example@example.com
Case Managers phone #
Please enter a valid phone number.Format: (000) 000-0000.
What day(s) of the week are you looking for respite care for? (check all that work for your family)

SaturdaySundayTuesdayWednesdayThursdayFriday
How many hours of respite are you hoping for each week?
What diagnoses (if any) does your child have? *
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?*
What are your child's greatest areas of need? (Check all that apply)*

Sensory RegulationAttention and FocusMotor CoordinationSocial ParticipationEmotional RegulationTransitions between activitiesDaily living skills (tolieting, grooming, bathing, dressing)Maintaning a routine
What type of sensory activities does your child like the most? (check all that apply)*

arts and craftsgames (card games, board games)building or constructingwater or messy playmovement/obstacle coursescooking/food funteamwork activitiesmusicplaydough/slimeriding bikes
What environments does your child work best? (check all the apply) Please note that although kids have their own hangout buddy, there may be instances where your child can play with other kids in small groups.*

individual play with their hangout buddy2-3 children play group4-6 child playing togetherlarger groups (8-10 kids)
What room or area of the Sensory Zone does your child LOVE the most? Click all that apply.*

GymCalming RoomToddler ZoneTouch wall areaQuiet NookGame RoomOutside fenced in area
Does your child have any allergies? If so, to what? *
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.

YesNo
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 stairsputting on or tying their shoesopening 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 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 packtylenol (childrens)basic medical attention (scratches, bumps, bruises)cough droppopsicle for sore throat
Other infomation not asked for that you feel is important:*
Introductory respite period: All children will begin with a 3-week introductory period to become familiar with our respite program, meet respite staff, and interact with other children. After three weeks, the office manager will connect with the family to review how things have been going, discuss any needed adjustments, and finalize respite services moving forward.
Please initial
Attendance Policy: To ensure we can maintain appropriate staff-to-child ratios and provide consistent care for all families, we ask that attendance be taken seriously. Our program follows a 3 unexcused absence policy. If a child has three (3) unexcused absences, they will be removed from our schedule. Absences due to illness, emergency, or other unavoidable circumstances will be excused and understood. If you are unable to attend your scheduled respite time, please notify us as soon as possible by texting the program cell at 608-640-8432.
please initial
Behavioral Agreement: The safety of all children and staff at the Sensory Zone is of the utmost importance. To maintain a safe and supportive environment, the Sensory Zone enforces a zero-tolerance policy regarding destruction of property or harm to others. If a child displays behaviors that include damaging property or physically harming another child or staff member, an immediate call home will be made. The child will be separated from all other children while waiting for a parent or guardian to pick them up. Future attendance in respite or any Sensory Zone programs will be discussed on an individual basis to determine the child’s ability to safely participate moving forward. Thank you for your understanding and support in keeping our space safe for everyone.
Please initial
Emergency Contact person (non guardian to contact in case of an Emergency) *

First NameLast Name
Emergency Contact phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Signature
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