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Respite Registration at New Life Community Church
Please fill out the information below so we can best meet the needs of your child. Thank you.
Email questions to
jessica@newlifescottsdale.org
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Events begin at 6pm. Pick up is at 8pm
Doors open at 5:45pm
Name of child/adult:
Your answer
Age:
Your answer
Name of parents/guardians/caregivers:
Your answer
Phone number(s):
Your answer
Alternate Emergency contact (name & phone #):
Your answer
Aside from parents, what other person(s) is authorized to pick up your child? (must be 18 yrs. or older)
Your answer
They enjoy...
Your answer
These things might upset them:
Your answer
What is their diagnosis?
Your answer
What strategies can we use to help calm your child if he/she is upset?
Your answer
Any other additional information you would like to provide our volunteers?
Medications, dietary restrictions, toiletling instructions, etc.
Your answer
I give New Life Community Church permission to take a picture of my child for the New Life Community Church database and/or for publication purposes.
Yes, for database only
Yes, for database and publications (websites, flyers, etc.)
No
Initials:
Your answer
I give New Life Community Church permission to take any necessary actions to ensure the safety of my child.
Taking any medical or physical precautions or calling authorites for an emergency
Yes
No
Clear selection
Initials:
Your answer
If your child has a severe food allergy, please bring a snack with him/her and check it in at the registration table.
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