FAMILY REGISTRATION DETAILED

FAMILY REGISTRATION
Contact Information & Agreement
Retreat Location*
How did you hear about the retreat?*
Names will be printed on name tags as listed.

Include only those attending with you.
Primary Contact*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Spouse (if applicable)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone*
Email*
example@example.com
Emergency Contact*

Full NameRelation
Emergency Contact Phone*
Name of the church you attend if applicable:

Family Member(s) with Special Needs*

	Full Name	Relation	Gender	Allergies	DOB
1
2
3
4
5
6

Other Family Members

	Full Name	Relation	Gender	Food Allergies	DOB
1
2
3
4
5
6

T-Shirt sizes for each family member (XS, S, M, L, XL, XXL, etc.):
Accessibility:

We require a room without steps or stairs for entry.
Other Information:*

This our first Guidelight Retreat.We you utilize attendant care at home.Male Buddy PreferedFemale Buddy PreferedWe consent to our contact information being shared with other family attendees at the end of the retreat. (Regardless of your answer, we won’t share your information with any other organization.)
I give my consent that information on this registration may be communicated to retreat leaders and volunteers for the purpose of being equipped to provide the best care and assistance possible to my family.

I give my consent that photographs, interviews and audio/video recordings during the course of the retreat may be used by Guideligth for training, promotion and fundraising.

I release Guidelight, its employees and volunteers, and the retreat facility from all actions, damages or personal injuries which may occur to me or a member of my family. I understand in the event of a minor injury I, or a member of my family, may receive first aid treatment. I will be informed as soon as possible of any injury or condition of one of my family members and will be responsible thereafter for their care. In the event of an emergency, injury, or illness, emergency medical services and I will decide the best course of action. If the retreat leaders are unable to reach me, I authorize them to take whatever action is necessary for the safety and health of my family members.

I understand that in order for everyone to experience a sense of calm, peaceful relaxation, the retreat is an alcohol, drug, and smoke free environment. Use of cell phones is discouraged except when necessary.
Signature*
MonthDayYear
Date
Family Registration - Health Information
Name*

Name of Individual with Special NeedsLast Name
Gender*
Date of Birth*

MonthDayYear
Date
Diagnosis (include pertinent medical information)*
Spectrum of Special Needs*
What are his/her strengths? What are some things that s/he is interested in and enjoys doing?*

Are there any health and medical needs we can be aware of that would allow us to best support your child? Check all that apply, please provide more detail in the prompts after this chart:*

	Answer
None
Seizures
Currently taking medication (detail below)
Allergies (environmental, food, medicine, etc.), detail below
Eating difficulties
Sensory needs (noises, visual stimulations,etc.)
Other health impairments or medical needs

Seizures, please describe types and frequency of seizures or other helpful information.
Medications, what medications for your child would be helpful for us to know.*
Allergies, please describe specific allergies so that we can prepare for dietary or environmental needs.*
Eating difficulties, are there certain kinds of food that are preferred or other pertinent needs with regards to food/feeding.*
Sensory, provide detail on sensory likes/dislikes or activities/settings that should be avoided.*
Mobility, describe your child's mobility challenges in more detail. If mobility is limited, please provide examples of what can be helpful for their inclusion in group and activity settings.*
Other health impairments or medical needs.*
What sort of activities and supports does your child need (sitting, standing, wandering, eating, etc.)?*
What would be helpful for your child to adapt into a larger group of children?*
What characteristics would be most helpful in the volunteer who will serve him/her?*
Are there any specific ways we can make the retreat as enjoyable as possible for him/her?*

Name

Name of Individual with Special NeedsLast Name
Gender
Date of Birth

MonthDayYear
Date
Diagnosis (include pertinent medical information)
Spectrum of Special Needs
What are his/her strengths? What are some things that s/he is interested in and enjoys doing?

Are there any health and medical needs we can be aware of that would allow us to best support your child? Check all that apply, please provide more detail in the prompts after this chart:

	Answer
None
Seizures
Currently taking medication (detail below)
Allergies (environmental, food, medicine, etc.), detail below
Eating difficulties
Sensory needs (noises, visual stimulations,etc.)
Other health impairments or medical needs

Seizures, please describe types and frequency of seizures or other helpful information.
Medications, what medications for your child would be helpful for us to know.
Allergies, please describe specific allergies so that we can prepare for dietary or environmental needs.
Eating difficulties, are there certain kinds of food that are preferred or other pertinent needs with regards to food/feeding.
Sensory, provide detail on sensory likes/dislikes or activities/settings that should be avoided.
Mobility, describe your child's mobility challenges in more detail. If mobility is limited, please provide examples of what can be helpful for their inclusion in group and activity settings.
Other health impairments or medical needs.
What sort of activities and supports does your child need (sitting, standing, wandering, eating, etc.)?
What would be helpful for your child to adapt into a larger group of children?
What characteristics would be most helpful in the volunteer who will serve him/her?

Name

Name of Individual with Special NeedsLast Name
Gender
Date of Birth

MonthDayYear
Date
Diagnosis (include pertinent medical information)
Spectrum of Special Needs
What are his/her strengths? What are some things that s/he is interested in and enjoys doing?

Are there any health and medical needs we can be aware of that would allow us to best support your child? Check all that apply, please provide more detail in the prompts after this chart:

	Answer
None
Seizures
Currently taking medication (detail below)
Allergies (environmental, food, medicine, etc.), detail below
Eating difficulties
Sensory needs (noises, visual stimulations,etc.)
Other health impairments or medical needs

Seizures, please describe types and frequency of seizures or other helpful information.
Medications, what medications for your child would be helpful for us to know.
Allergies, please describe specific allergies so that we can prepare for dietary or environmental needs.
Eating difficulties, are there certain kinds of food that are preferred or other pertinent needs with regards to food/feeding.
Sensory, provide detail on sensory likes/dislikes or activities/settings that should be avoided.
Mobility, describe your child's mobility challenges in more detail. If mobility is limited, please provide examples of what can be helpful for their inclusion in group and activity settings.
Other health impairments or medical needs.
What sort of activities and supports does your child need (sitting, standing, wandering, eating, etc.)?
What would be helpful for your child to adapt into a larger group of children?
What characteristics would be most helpful in the volunteer who will serve him/her?
Are there any specific ways we can make the retreat as enjoyable as possible for him/her?
Are there any specific ways we can make the retreat as enjoyable as possible for him/her?

What are your child(ren)’s strengths? What are your child(ren)’s interests? Please list for each sibling.*
What characteristics would be most helpful in the volunteer who will serve your child(ren)? Please list for each sibling.*
Are there any specific ways we can make the retreat as enjoyable as possible for him/her?*

Should be Empty:

FAMILY REGISTRATION

Contact Information & Agreement

Family Registration - Health Information