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Taraweeh Respite Care Registration
Ramadan Mubarak! If you would like respite care for your child with special needs during Taraweeh, please fill out this form below at least 24 hours before the event
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First and Last Names
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Your answer
Child's Name
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Your answer
Email(s)
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Your answer
Phone Number(s)
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Your answer
I understand that this is to register for one time only.
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Yes
No
Other:
Required
Keeping in mind that respite care is only available for Wednesdays and Saturdays, I am requesting the following date:
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MM
/
DD
/
YYYY
Please descirbe your child's interests
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Your answer
Do you have any concerns for your child? (Sample Concerns: using the bathroom, eating habits or allergies, extreme dislikes, etc.)
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Your answer
Please describe your child's medical needs, if any. (Write "n/a" if none)
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Your answer
Does your children have or do any of the following? (Check all that apply)
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Elopes
Seizures
Self injurous behavior when frustrated
Other:
Required
Please let us know what we need to do in the event that your child has or does any of the above things while in our care
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Your answer
Is there anything else you need us to know?
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Your answer
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