Upper Eastern Shore Family Leadership Retreat
Registration & Commitment Form: Each potential participant must complete an application
Name: *
Your answer
Address: *
Your answer
City, State, Zip: *
Your answer
County of Residence: *
Your answer
Phone: (where you can be reached most often) *
Your answer
Email: (that you use regularly) *
Your answer
Emergency Contact Name: *
Your answer
Emergency Contact Telephone Number: *
Your answer
I am the caregiver of a child with mental health needs. My relationship to the child is: *
Required
Have you in the past, or are you currently working with a member of the MCF team? *
If you answered yes above, please share with whom and for how long you have had contact, and in what capacity you have/are working with MCF. *
Your answer
Age of child or children with mental health needs: *
Your answer
If a diagnosis(es) has been identified, please list it/them here. Please include all diagnoses. *
Your answer
Is your child currently registered and attending school?
Does your child have a 504 plan or IEP?
Has your family had any involvement with the Department of Social Services or the Department of Juvenile Services? *
If you answered yes above please indicate which agency you have had involvement. *
Required
Is your child currently receiving Targeted Case Management (TCM) services? *
Do you have other children? If so, what are their ages? *
Your answer
What are your current challenges as a caregiver to a child/children with mental health needs? *
Your answer
What do you hope to gain by your participation in the Family Leadership Retreat? Please identify three goals you hope to achieve by attending. *
Your answer
If any special accommodations are needed to enable your participation, please describe them:
Your answer
Please list any special dietary needs we should be aware of:
Your answer
Lodging is included, but not required, at Holiday Inn Express and Suites,150 Scheeler Road Chestertown, MD 21620. Rooms are double occupancy (2 people). If you are attending by yourself and wish to stay, we will assign you a room with another participant at the retreat. Couples will share with each other. Would you like us to provide lodging on November 3? *
Required
Financial assistance will be available for childcare and transportation based on financial need and available funds. This stipend does not cover actual cost, but is meant to help offset the cost of transportation and childcare. Please indicate if you will apply for the following:
If you have previously participated in MCF trainings or events, please list them below along with the year you attended:
Your answer
How did you hear about the Family Leadership Retreat? *
Your answer
Participant Commitment: Because space is limited, we require that you commit to attend both the Friday evening and Saturday sessions including meals. We also ask that you notify us if, after registering and being accepted, your circumstances change and you are no longer able to attend so we can offer a place to another parent or caregiver. *
Please direct any questions to Noelle Nicharot at: nnicharot@mdcoalition.org or 410-660-9350.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms