APPLICATION: RESPITE CARE PROGRAM

A copy of this information will be supplied to Respite Providers caring for your child/ren.

Personal

 

 

 

Living Arragements

Additional Children In The Home


Additional Living Arrangments

 

Health Information

 

Diagnosis

Select all that apply.

 

Medication List

Name of Medication, Dosage, Frequency, Distribution Method (orally, shot, etc), and Side Effects (if applicable)

 

Seizures

 

Emergency Information

Persons to be called when parents cannot be reached.

 

 

Local Emergency Contacts (List Names and Phone Numbers)

 

Behavior Concerns

Interests

 

 

Communication

 

 

Daily Living Skills

Please specify the type and degree of help required for the following daily living skills.

 

 

Sibling Information

List all siblings names/age/D.O.B. related to child applicant

 

Sibling's Schedule

 

Siblings Meal Times

 

Siblings Special Instructions

 

Siblings Play Activities