Respite Care Registration Form Please complete this form to help us better understand your needs. {"field_905dbb4":{"display_mode":"show","fire_action":"All","file_types":"png","logic_data":[{"cfef_logic_field_id":"field_72320f1","cfef_logic_field_is":"==","cfef_logic_compare_value":"Yes","_id":"729ae66"}]}} Parent/Guardian Name(s . Address City State Zip Code Phone Number Secondary Email Address Preferred Contact Method Phone Email Child’s Name . Date of Birth Diagnosis/Condition Does your child have an Individualized Education Plan (IEP) or 504 Plan? Yes No Child’s Allergies (if any) Does your child require any medications during respite care? Yes No If yes, list medications and instructions: Child’s Favorite Activities or Comfort Items: Triggers or Sensitivities Behavioral Challenges or Concerns Communication Style Primary Emergency Contact 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? Submit
