Respite Intake Form

Respite Intake Form

Gather essential information for respite care planning
Parent Information
Parent Full Name*

First NameLast Name
Parent Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent Email Address*
example@example.com
Upload Driver’s License*

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Child Information
Child Full Name*

First NameLast Name
Child Age*
Child Grade*
MaleFemale
Upload Recent Picture of Child*

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Emergency Contact
Emergency Contact Full Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child*
Medical Information
Medical Conditions, Allergies, and Medications (with dosage)*
Dietary Restrictions or Preferences*
YesNo
Upload IEP Document

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Please upload a copy of your child's insurance card

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Behavioral and Social Information
Please describe any behavioral supports or strategies that help your child succeed.*
PicaTantrumPulling HairScreamingElopementSpittingAggression (physical or verbal)Other
Are there any social behaviors or concerns we should be aware of?*
VerbalNon-VerbalAAC DeviceGesture/Sign LanguagePictures1-2 Words
Waiver of Release and Indemnification Agreement for Minors

Please read and agree to the waiver below.
I, the parent or legal guardian of the above-named child, hereby release and hold harmless the camp, its staff, and volunteers from any liability or claims for injury, loss, or damage to person or property arising from participation in camp activities, except in cases of gross negligence or willful misconduct. I acknowledge that I have read and understand this waiver and indemnification agreement.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR PARTICIPANT’S INJURY OR DEATH OR DAMAGE TO PARTICIPANT’S PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITY OR TRIP AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY PARTICIPANT’S NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
📹 Video Surveillance Acknowledgment
For the safety and supervision of all campers, Joyful Roots Camp utilizes video surveillance in common areas of the center, including activity rooms, the sensory gym, hallways, and entry/exit points. Cameras are not located in bathrooms or private areas.
Video is used for safety, supervision, and incident review purposes and is securely stored. Audio recording is not conducted unless otherwise disclosed in writing.
Video footage is the property of Joyful Roots Foundation and is not automatically released upon request.
Please ensure that your child brings a snack and a drink of their choice each day. Kindly label all items clearly with your child’s name.
LATE POLICY

Fees apply
A 15-minute grace period is provided from your scheduled pick-up time. After the grace period, a late fee of $10 per minute will be charged.
Parent/Guardian Acknowledgment & Certification*
4/18/26 - 10am-2pm4/25/26 - 9am-1pm5/16/26 - 10am-2pm5/30/26 - 5pm-9pm

My Products

April 18th, 2026

$100.00 Quantity

April 25th, 2026

$100.00 Quantity

May 16th, 2026

$100.00 Quantity

May 30th, 2026

$100.00 Quantity

Total

$0.00

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Respite Intake Form

Parent Information

Child Information

Emergency Contact

Medical Information

Behavioral and Social Information

Waiver of Release and Indemnification Agreement for Minors

📹 Video Surveillance Acknowledgment

LATE POLICY