Member Respite - July 2024
Please complete the form below to register for the Saturday, July 13th Respite event at Marcus Pointe Baptist Church from 10:30 AM to 1:30 PM. We recommend that participants have a packed lunch or bring drinks and a snack to have on hand during respite. If your child has a preferred item that they would like to bring, please be sure to label those items with their name. At this time, we are only permitting a maximum of 12 participants each month. Attendees must be ages 4 and older. If your child is not toilet-trained, please be sure to include a change of clothes and any diapering supplies they may need at drop-off.**You must have a current paid 2024 Autism Pensacola Membership level of Household ($50 annually) or higher to participate. Respite is a part of Autism Pensacola's member perk program and is only available for your calendar year maximum of complimentary benefits allotted to your membership level. If you have questions on the number of benefits you have available, please email shanan@autismpensacola.org.
Parent/Guardian First & Last Name
First Name
Last Name
Best Phone Number
Please enter a valid phone number.
Email
example@example.com
What is your 2024 Membership level?
Please Select
Household ($50 Annually)
Connector ($100 Annually)
Business & Community Leader ($150 Annual)
Sustaining Member ($10 or more monthly)
Provide the name, age, and special needs of each child attending
Child's Preferred Activities
Arts & Crafts
Coloring
Sensory Play
Puzzles
Board Games
Legos
Blocks
Kinetic Sand
Movies
Bubbles
Dancing
Singing
Card Games
Painting
Other
Will your child need any prescription medications administered during respite?
Yes
No
If answered "yes" to medications, please list them below:
Please provide the names & phone numbers of other authorized adults for drop-off and pick-up:
Submit
Should be Empty: