APPLICATION: RESPITE CARE PROGRAM
A copy of this information will be supplied to Respite Providers caring for your child/ren.
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
