THRIVE-RESPITE EVENT REGISTRATION

Date*

Date

Child's Name *

First NameLast Name

Birthday *

Age*

GENDER*

MALEFEMALE

Child lives with ...*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Father's Name *

First NameLast Name

Phone Number*

Area CodePhone Number

Address(If different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mother's Name *

First NameLast Name

Phone Number*

Area CodePhone Number

Address (If different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Alternate Emergency Contact *

First NameLast Name

Phone Number*

Area CodePhone Number

What is your child's diagnosis? What health concerns should we be aware of?*

Does your child have seizures *

YESNO

If yes, what should be done if your child has a seizure during the respite event?

Please describe your child's allergies, specifically food allergies.

Under what circumstance would you like to be notified during the respite event?*

VISION *

NormalPartialImpairedBlind

Hearing*

Motor*

Uses*

WalkerCrutchesBracesWheel Chair

What sensory needs does your child have?*

Does your child have any special toileting/self-care needs?*

What sort of things upset your child?*

What activities help to calm your child if he/she is upset?*

What behavior and/or learning strategies work best with your child at school?*

Is there additional information you would like our volunteers to know about your child such as personality traits, behaviors, likes and dislikes, etc.?

Does your family attend a church in the community?*

YesNo

If yes, which one?

Aside from parents, please list other person(s) authorized to pick your child(ren). Please note, any person(s) authorized to pick up your child(ren) must be at least 18 years old.

First NameLast Name

Age

First NameLast Name

Age

RESPITE EVENT REGISTRATION FORM

IF YOUR CHILD HAS FOOD ALLERGIES,PLEASE BRING A SNACK AND CHECK IT IN WITH THE NURSE WHEN YOU ARRIVE

Thank you so much, we look forward to serving you and your family!