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Home
About
Mission & Vision
History
Staff
Board
Child Protective Policy
Parent Testimonials
Respite
Respite Program
Respite Care Application-đŸ’¥MANDATORY-fill out first
Special Needs Child Information Form
Medical Information Form
Sibling Information Form
Friday NITE Friends Medical Release Form
Overflow
Overflow Program
Overflow Application
Overflow Applicant Information Form
Overflow Medical Release Form
Calendar
Donate
DONATE NOW
Volunteer Meals
Christmas Party
Volunteer
Volunteer Information
Volunteer Application
Featured Volunteers
Gallery
Connect
Contact Us
What’s Happening
Parent’s Corner
Lending Closet
Respite Care Application-đŸ’¥MANDATORY-fill out first
If you are human, leave this field blank.
Family Information
Mother's Name
Cell Phone
Address
City
State
Zip
Other Phone
Email
Father's Name
Cell Phone
Address
City
State
Zip
Other Phone
Email
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
No
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
Submit
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