Respite Care Application

Family Information
CHILD(REN) WITH SPECIAL NEEDS:
SIBLINGS
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)
SERVICES CURRENTLY BEING RECEIVED
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.
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.
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.
I will supply all necessary food, drinks, snacks and diapers/wipes for my children.
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.
I have read and initialed the above permission/authorization statements and agree to the terms designated in each.
V. PUBLICITY RELEASE
Pictures and film may be taken at Friday NITE Friends for the purposes of publicity, pictorial recordings and identification.
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