Clone of Oklahoma Family Caregiver Respite Retreat Interest Form

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Thank you for your interest in the Pottawatomie Family retreat. Let's get started with a couple of questions. Do you have a child with special health care needs?Special health care needs: Children with special health care needs are children who have a long-term health, developmental, behavioral, or emotional condition—or are likely to develop one—and need more health care, services, or support than most children their age.

YESNO

2

Thank you for your interest in attending this family retreat in Pottawatomie County. This retreat is only for families with chidlren with special health care needs.

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We plan to host this family retreat in Pottawatomie County. We would love to connect with you to share more details. Note: There is no guarantee of retreat attendance as spots are limited. We will review interest forms in the order in which they are received. May we contact you by phone or email?

YESNO

4

Caregiver’s Name

First Name

Last Name

5

Your Phone Number

Please enter a valid phone number.

6

Email Address

example@example.com

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Please let us know which COUNTY you live in.

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If you are interested in locating a respite voucher program that will meet the needs of your family or are in need of any other resources, services, or information, please visit our website soonersuccess.ouhsc.edu or call us at 405-271-2710

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You must click "SUBMIT" below to complete your interest form. Thank you for your information. We will contact you to share more details on the retreat.