Respite Night Registration

Restoration Respite Night Registration

When: April 24, 2026. Time; 6:00pm-9:00pm Where: Restoration Purpose Church Bailey, NC 27807
Parent/Caregiver Information

Deadline to Register is APRIL 20, 2026
Parent/Caregiver Name

First NameLast Name
Date and Time Stamp

MonthDayYear
Date
Hour Minutes
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Full Name (Other than a parent)

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Special Needs Individual Information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diagnosis/ Primary Needs
Age
Diagnosis
Mobility Needs
Communication Needs
Toileting Needs
Behavioral or Sensory Considerations:
Plase check all that apply
Allergies/Dietary Restrictions:
What foods is the child/adult allergic to?
Medications (if any). NOTE: We do not administer medication; please list for awareness in case of an emergency)
Sibling Information
Will Siblings attend?
If siblings will attend, please list their Full Name, Age, Allergies/Dietary Needs, or additional helpful information.
Event Details
Date of event 4/24/2026 Time: 6pm-9pm. Location: Restoration Purpose Church. Please register by 4/20/2026 to be listed as a registered guest. Please register at the door upon arrival. Obtain a sticker for you and other siblings. This will be used for pick up at the end of the event at 9pm.
Medical and Safety Permission
In the event of an emergency, do we have your permission to seek medical care for your child?
Primary Care Doctor Name & Phone
Photo/Video Permission
Do you consent to photos or videos of your child(ren) being used for the organization updates, promotions, website, or social media?
Coffee and Conversation with the Ark

We are inviting the parents to stay and visit our friends from The Arc. There will be a parent only lounge area for our families to meet others, eat dinner, play games (win prizes) and gain lots of information on how to help their kids/adults with disabilities. If you would like to be a part of this fun event while your children/adults are in the next room, please register here.
How many adults in your family will attend Coffee and Conversation during the Respite Night? Please indicate 0 or 2 adults
Name of each adult who will attend the Coffee and Conversation event.
Parent/Guardian Consent/Signature
Signature
Should be Empty:

Restoration Respite Night Registration

Parent/Caregiver Information

Special Needs Individual Information

Behavioral or Sensory Considerations:

Allergies/Dietary Restrictions:

Sibling Information

Event Details

Medical and Safety Permission

Photo/Video Permission

Coffee and Conversation with the Ark

Parent/Guardian Consent/Signature