Parish Outreach

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Click Here to Download/Print Respite Night Volunteer Form (Students & Adults)

Fill out the form below for Respite registration.

Participant Information

Name(Required)

First Last

Age(Required)

Date of Birth(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Mother's Name(Required)

First Last

Phone(Required)

Father's Name(Required)

First Last

Phone(Required)

Primary Email(Required)

Emergency Contact

Contact for Respite night(Required)

First Last

Phone(Required)

Education/Communication

School(Required)

Grade level(Required)

Classification or disability(Required)

Services your child receives(Required)

How can they communicate?(Required)

Advice to volunteers on how to communicate with your child(Required)

Soothing techniques that work for your child(Required)

Child Medical Information

Please list any medical conditions(Required)

Does your child take any medications?(Required)

Please note: we are not able to keep or administer medications at Respite

Please list any allergies(Required)

Toileting: any assistance needed?(Required)

Any food allergies/sensitivities? Do you plan to send food for your child?(Required)

Activities

Special abilities(Required)

Any fears or behavioral triggers?(Required)

What is of interest to your child?(Required)

Board Games

Gym Activities

Puzzles

Music

Sports

Arts & Crafts

Strategies for your child that are helpful at home or school i.e. behavior chart, visual schedule, etc.(Required)

What do you hope for your child from the Respite experience?(Required)