Respite service request form

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Dear parents please sign your child for a respite service if you need. Respite service would be provided each Saturday 1 pm - 3 pm and include outdoor activity and art and craft in recreational centre. Child would be picked up from your address and dropped off at your building. Additional forms might be needed to sign, would be sent separately, thank you. For any questions, or concerns please email or call me with no hesitation, thank you.
Shakhlo
647-606-5732
sh2010sharipova@gmail.com

Full name of the parent. *

Full name of the child *

Date of birth of the child. *

YYYY

Home address *

Any of your contacts (phone number or email, or both) easy to reach for emergency situation, thank you. *

Is your child in wheelchair? *

Yes

Additional info you would like to provide, thank you.

Submit

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