Please indicate in which program you have an interest. If you are enrolling children in respite AND Sibshops, you will need to complete a form for each child:
Sibshops Only (for siblings of children with special needs ages 5-12)
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Contact Information in Case of Emergency
Name of Contact
First Name
Last Name
Contact Number
-
Area Code
Phone Number
Relationship to child
Name of Additional Contact
First Name
Last Name
Contact Number
-
Area Code
Phone Number
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Sibshops Program Participant
(Sibling of Child with Special Needs/Special Health Care Needs)
Name of sibling attending Sibshops Program
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
School
Parent/Guardian name
First Name
Last Name
Mobile Phone Number
Alternate Phone Number
Email
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Sibling with Special Needs/Special Health Care Needs
Age of Sibling with Special Needs
Gender
Male
Female
Name or description of disability of health concern of sibling with disability
Other siblings names/ages
Any issues we should be aware of while your child is in our care?
What do you hope your child will gain from participating in Sibshops?
Does your child attending Sibshops have any food allergies or other health restrictions of their own that we should know about?
Yes
No
If yes, please explain
Who has permission to pick up child (list all)?
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Sibshops Program Participant
(Sibling of Child with Special Needs/Special Health Care Needs)
Name of sibling attending Sibshops Program
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
School
Parent/Guardian name
First Name
Last Name
Mobile Phone Number
Alternate Phone Number
Email
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Sibling with Special Needs/Special Health Care Needs
Age of Sibling with Special Needs
Gender
Male
Female
Name or description of disability of health concern of sibling with disability
Other siblings names/ages
Any issues we should be aware of while your child is in our care?
What do you hope your child will gain from participating in Sibshops?
Does your child attending Sibshops have any food allergies or other health restrictions of their own that we should know about?
Yes
No
If yes, please explain
Who has permission to pick up child (list all)?
Do you have another Sibling you would like to attend the Sibshops Program?
*
Yes
No
Submit
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Terms of Participation
Signature of parent or guardian
Submit
Please click "SUBMIT" to complete your forms.
Should be Empty: