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 Phone Email Child’s Name . Date of Birth 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 I understand, if they are not potty trained you will need to bring wipes and diapers. Primary Emergency Contact Secondary 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. 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
