Fearfully & Wonderfully Me! Respite Care Services Registration

Fearfully & Wonderfully Me! Respite Care Services Registration

Please fill out this application in its entirety. Incomplete applications will result in automatic denial of services.
Please choose which respite care date(s) and location(s) you are signing up for. Please check all that apply. Payments will not be taken until the application is accepted. Only 4 applications will be accepted per date. Respite Care services are for children ages birth-18 years of age.
Care Recipient's Full Name

First NameLast Name
Please list the care recipient's diagnosis/diagnoses that would make him/her an appropriate candidate for respite care services.
Care Recipient's DOB (00-00-0000)
What is the care recipient's preferred mode of communication? Please check all that apply.
If applicable, what is the name of the care recipient's school attending? Type N/A if not applicable.
If applicable, what grade will the care recipient be entering for the 2026/2027 school year? Type N/A if not applicable.
Is the care recipient toilet trained? Please check all that apply.
If applicable, please list any dietary restrictions. Type N/A if not applicable.
If applicable, please list any challenging behaviors the care recipient displays. Type N/A if not applicable.
How often does the care recipient display these behaviors?
Parent/Guardian Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Respite Care Service Agreement
Signature
Should be Empty: