Respite Care Application-💥MANDATORY-fill out first

Family Information

Mother's Name

Cell Phone

Address

City

State

Zip

Other Phone

Father's Name

Cell Phone

Address

City

State

Zip

Other Phone

PARENTS ANNIVERSARY / SINGLE PARENT BIRTHDAY

CHILD(REN) WITH SPECIAL NEEDS:

Name

Diagnosis

Age

M/F

DOB

Name

Diagnosis

Age

M/F

DOB

SIBLINGS

Name

Age

M/F

DOB

Name

Age

M/F

DOB

Name

Age

M/F

DOB

Name

Age

M/F

DOB

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

Phone

Address

Relationship

SERVICES CURRENTLY BEING RECEIVED

DO YOU CURRENTLY RECEIVE ANY NURSING CARE OR RESPITE SERVICES

Yes

HOW MANY HOURS OF NURSING CARE DO YOU RECEIVE

INDICATE IF THAT IS PER DAY OR PER WEEK

PER DAY

PER WEEK

Permission and Authorization Agreement

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

If my child is enrolled in the Medical Respite Program, I understand care will be provided by contract nurses from a licensed home health agency. I authorize the nursing staff to provide any required special treatments or procedures to my child while in respite care. I will provide written authorization, instructions and all necessary supplies, and equipment for these procedures.

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

I will supply all necessary food, drinks, snacks and diapers/wipes for my children.

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

I have read and initialed the above permission/authorization statements and agree to the terms designated in each.

Signed (type name)

Date

V. PUBLICITY RELEASE

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