Respite Care Registration Form (non-members)

Click Here to Register for Stress to Strength

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Respite Care Registration Form (non-members)

Respite Care Registration Form

Please complete this form to help us better understand your needs.

Parent/Guardian Name

Address

City

State

Zip Code

Phone Number

Secondary

Email Address

Preferred Contact Method

Child’s Name

Date of Birth

Diagnosis/Condition

Does your child have an Individualized Education Plan (IEP) or 504 Plan?

Child’s Allergies (if any)

Child’s Favorite Activities or Comfort Items:

Triggers or Sensory Input

Behavioral Challenges or Concerns

Communication Style

Is your child potty trained?

Yes No

If they are not potty trained please make sure to bring diaper and wipes

Yes, I understand that I'm responsible for diapers and wipes.

Primary Emergency Contact

Parental/Guardian Consent

Permission for Emergency Medical Care

I hereby give permission for MAAM staff to seek emergency medical care for my child if necessary.

Signature

Date

Photo/Video Consent

I grant / do not grant (circle one) permission for MAAM to use photos or videos of my child for program purposes or promotional materials.

Acknowledgment of Policies

I understand and agree to abide by MAAM’s policies regarding respite care services.

Signature

Date

Is there anything else you’d like us to know about your child or family needs?

Click Here to Register for Stress to Strength

Respite Care Registration Form (non-members)

Respite Care Registration Form

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