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Respite registration
April18,2020 1:00 pm to 5:00 pm
8897 Byrom Campbell Road Pace, FL 32570
Email address *
Special needs attendee name *
Your answer
Address
Your answer
Age of attendee *
Your answer
Attendee diagnosis of disability *
Your answer
Check all that apply
Speech Communication
Does the attendee need assistance with the following?
Please list medical equipment needed during respite
Your answer
Does the attendee use any of the following?
Please list any sensory impairments
Your answer
Is there a second attendee with special needs? If yes, proceed to next question. If no, proceed to sibling information. *
Additional attendee(s) with Special Needs
Fill out this section if there is an additional child/loved one with a special need.
Second Special Needs Attendee Name
Your answer
Age of attendee No. 2
Your answer
Attendee No. 2 diagnosis of disability
Your answer
Check all that apply to attendee No. 2
Speech Communication of attendee No. 2
Does attendee No. 2 need assistance with the following?
Please list medical equipment needed during respite for attendee No. 2
Your answer
Does the attendee No. 2 use any of the following?
Please list any sensory impairments of attendee No. 2
Your answer
Sibling Information
How many siblings will attend? *
Required
Names and ages of siblings attending (write "none" if there are no siblings) *
Your answer
Additional Information
Please list any dietary restrictions of attendee(s) *
Your answer
Please list any allergies of attendee(s) *
Your answer
Please list anything else that we should know about the attendee(s)
Your answer
Parent/Caregiver Contact Name(s) & Number(s) *
Your answer
Emergency Contact Name & Number *
Your answer
Waiver and Release
By agreeing, I confirm that I am the parent/legal guardian of the individual(s) listed above and have read the waiver and release and agree to all terms set before me. This acknowledgement acts as my signature. *
By agreeing, I confirm that I am the parent/legal guardian of the individual(s) listed above and agree that I have answered all questions truthfully and to the best of my ability. This acknowledgment acts as my signature. *
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