Application for Respite Services
Family Information
Parent Information
Name
Your answer
Address
Your answer
Cell Phone
Your answer
Email
Your answer
Parent Information
Name
Your answer
Address
Your answer
Cell Phone
Your answer
Email
Your answer
Child(ren) Requiring Special Supervision
Child 1
Name
Your answer
Age
Your answer
DOB
Your answer
Gender
List and Describe your child's diagnosis
Your answer
Allergies
Drugs
Your answer
Food
Your answer
Insects/other
Your answer
List anything important you would like us to know about your child:
Your answer
Care Needs
Vision
Hearing
Motor
Please describe any special positioning needs your child may have
Your answer
Communication
Can communicate with others using
Describe other
Your answer
Language spoken at home
Your answer
Toileting Skills
Toileting Skills
How does your child indicate a need to use the toilet?
Your answer
Indicate special toileting needs/schedule:
Your answer
Eating Habits
Feeding/Drinking
Special Diet
(If your child is difficult to feed, please describe any special assistance or adaptive utensils required for eating):
Your answer
Behavior
Check all that apply
My child responds to separation from his/her parents by:
Your answer
My child is best comforted by:
Your answer
My child lets someone know what he/she wants or needs by:
Your answer
Child 2
Name
Your answer
Age
Your answer
DOB
Your answer
Gender
List and describe your child's diagnosis
Your answer
Allergies
Drugs
Your answer
Food
Your answer
Insects/other
Your answer
List anything important you would like us to know about your child:
Your answer
Care Needs
Vision
Hearing
Motor
Please describe any special positioning needs your child may have
Your answer
Communication
Can communicate with others using
Describe other
Your answer
Language spoken at home
Your answer
Toileting Skills
Toileting Skills
Indicate special toileting needs/schedule:
Your answer
How does your child indicate a need to use the toilet?
Your answer
Eating Habits
Feeding/Drinking
Special Diet
(If your child is difficult to feed, please describe any special assistance or adaptive utensils required for eating):
Your answer
Behavior
Check all that apply
My child responds to separation from his/her parents by:
Your answer
My child is best comforted by:
Your answer
My child lets someone know what he/she wants or needs by:
Your answer
Sibling Information
Sibling 1
Name
Your answer
Age
Your answer
DOB
Your answer
Gender
Sibling 2
Name
Your answer
Age
Your answer
DOB
Your answer
Gender
Sibling 3
Name
Your answer
Age
Your answer
DOB
Your answer
Gender
Emergency Contacts
In case of an emergency, the following person may be called and are authorized to pick up my child (at least one contact must be provided). Positive identification MUST be provided before your child will be released.
Contact 1
Name
Your answer
Phone
Your answer
Address
Your answer
Driver's License Number
Your answer
Relationship
Your answer
Contact 2
Name
Your answer
Phone
Your answer
Address
Your answer
Driver's License Number
Your answer
Relationship
Your answer
Services Currently Being Received
Early intervention program, school or day care your child is currently attending:
Your answer
Permission/Authorzation Agreement
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INITIAL IN THE DESIGNATED SPACE INDICATING THAT YOU HAVE READ, UNDERSTOOD AND AGREE TO THE PROVISION.

* I have fully disclosed to First Baptist McKinney all pertinent facts about my child(ren)'s special needs and accept full responsibilitiy for failure to do so.
* I understand that care for all children not enrolled in Incredible Fridays will be provided by trained volunteers. I understand that medications and treatments cannot be administered by volunteer nurses or any respite staff.
* I will supply any necessary food, drinks, snacks and diapers/wipes for my children.
* In case of an emergency or accident, I understand that emergency services (911) will be called. I authorize EMS to administer any medical treatment, medication or appliance deemed necessary by EMS. I also authorize transportation by EMS to the nearest appropriate medical facility as determined by EMS.
* I understand that I will be responsible for payment of all EMS, hospital and physician charges for emergency serviced to my child.
* I have read and initialed the above permission/authorization statements and agree to the terms designated in each.
Please initial: (your initials represent your signature) Date:
Your answer
Publicity Release
Incredible Fridays is a respite care program designated to lessen the stress of families caring for a child with special needs. Because we want to reach as many families as possible, we may publicize the program. The use of your name, your child(ren)'s name or picture is strictly voluntary. If you want to participate, please make your choice below, initial and date.
The picture may be used for press releases, journal articles or other positive publicity related to respite programs.
Please initial and date:
Your answer
Email List
Incredible Fridays often receives email information on subjects pertaining to Special Needs. These emails offer information on events for special needs children in the area. Not all of the emails are specific to Incredible Fridays, but they are very informative and may be of value to you and your family. If you would like to receive periodic emails from Incredible Fridays, please make your choice below, initial and date.
I may choose to stop receiving these emails at anytime.
List your email, initial and date
Your answer
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