Overflow Application – Friday NITE Friends

PARENT INFORMATION

Mother's Name

First

Last

Cell Phone

Address

City

State

Zip

Other Phone

Father's Name

First

Last

Cell Phone

Address

City

State

Zip

Other Phone

PARENTS ANNIVERSARY / SINGLE PARENT BIRTHDAY

Please indicate how many children with special needs from your family will be applying for Respite at Friday NITE Friends:

Number of Children*

1 Child

2 Children

3 Children

CHILD WITH SPECIAL NEEDS INFORMATION

IF you have more than one child with special needs, the form will allow for subsequent sets of information below.

Child's Name*

Male / Female*

Male

Female

Date of Birth*

WHAT IS YOUR CHILD’S DIAGNOSIS? (PLEASE LIST ALL PERTINENT DIAGNOSES)**

ALLERGIES*

Child's Name*

Male / Female*

Male

Female

Date of Birth*

WHAT IS YOUR CHILD’S DIAGNOSIS? (PLEASE LIST ALL PERTINENT DIAGNOSES)**

ALLERGIES*

Child's Name*

Male / Female*

Male

Female

Date of Birth*

WHAT IS YOUR CHILD’S DIAGNOSIS? (PLEASE LIST ALL PERTINENT DIAGNOSES)**

ALLERGIES*

LOCAL EMERGENCY CONTACT

IN CASE OF AN EMERGENCY, THE FOLLOWING PERSONS MAY BE CALLED AND ARE AUTHORIZED TO PICK UP MY CHILD: (AT LEAST ONE CONTACT MUST BE PROVIDED. Positive identification MUST be provided before your child will be released)

Name

Address

Phone

Relationship

I have fully disclosed to Custer Road United Methodist Church all pertinent facts about my child(ren)'s special needs and accept full responsibility for failure to do so.*

Yes

I understand that care for all children not enrolled in the Medical Respite will be provided by trained volunteers. I understand that medications and treatments cannot be administered by volunteers or any respite staff.*

Yes

In case of an emergency or accident, I understand that the Plano EMS (911) will be called. I authorize EMS to administer any medical treatment, medication or appliance deemed necessary by EMS. I also authorize transportation by EMS to the nearest appropriate medical facility, as determined by EMS. I understand that I will be responsible for payment of all EMS, hospital, and physician charges for emergency services to my child.*

Yes

Signed (type name)

Date

Pictures and film may be taken at Friday NITE Friends for the purposes of publicity, pictorial recordings and identification.

I DO / DO NOT give permission for my children to be photographed during Friday NITE Friends.*

I DO

I DO NOT

Signed (type name)

Date

This field should be left blank