Respite Program:
Child’s Name #1 ________________________ Age _______ Birth Date ________________________ Grade: ________ School: ____________________________ Sex: M F
Diagnosis/Disability: ___________________________________________________________________
Child’s Name #2 ________________________ Age _______ Birth Date ________________________ Grade: ________ School: ____________________________ Sex: M F
Diagnosis/Disability: ___________________________________________________________________
Emergency Contact #1: ___________________________ Relationship to Child: ____________________ Home Address: _____________________________ City: __________________ State :____ Zip: _______ Home Phone: ________________ Cell Phone: ____________________ Email: ______________________ Employer: _____________________ Address: _______________________ Phone: __________________
Emergency Contact #2: ___________________________ Relationship to Child: ____________________ Home Address: _____________________________ City: __________________ State :____ Zip: _______ Home Phone: ________________ Cell Phone: ____________________ Email: ______________________ Employer: _____________________ Address: _______________________ Phone: __________________
Child’s Physician: _____________________________ Phone Number: ___________________________
Waiver of participation and release of liability:
As a condition of participation in the program, I waive any and all claims against Jacob’s Ladder Pediatric Rehab Center, its affiliates and/or agents for injury or damage that may be sustained as a direct or indirect result of my child’s participation in program activities. _________ Initial
I give my consent to his/her being administered any emergency medical treatment by a physician or hospital in case of an accident or illness. ___________ Initial
By signing below, I am acknowledging that I have read and understand the policies, general information, and Liability Waiver outlined above.
Parent/Guardian Signature __________________________________ Date: ____________________
✔
The following information is necessary for our records and the funding our organization receives. Jacob’s Ladder depends upon outside funding to develop and sustain programs offered to its participants. Therefore your cooperation in providing this information is greatly appreciated. The answers you provide are confidential.
Ethnicity/Race (check only one):
☐African American ☐Caucasian/White ☐Hispanic/Latino
☐Asian ☐Native American ☐Other: ____________
Primary Language (check only one):
☐English ☐Spanish ☐Other: ____________
Family Income Level (Check only one)
☐Under $10,000 ☐$10,000 – $19,999 ☐$20,000 - $29,999 ☐$30,000 - $39,999 ☐$40,000 - $49,999 ☐$50,000 - $59,999 ☐$60,000 - $69,999 ☐$70,000 - $79,999 ☐$80,000 - $89,999 ☐$90,000 - $99,999 ☐$100,000 or higher
Does anyone in your household receive one or more of the following (check all that apply): ☐Free or reduced price lunch at school ☐Supplemental Security Income (SSI)
☐Food stamps ☐Medicaid
How did you hear about the Jacob’s Ladder Respite Program?
I understand that in order for my child to participate in the respite program that: 1. I will bring my child to each of the six (6) Saturdays over the six month period. 2. I agree to pay $20.00 for each of the six (6) Saturdays.
3. I will participate in a minimum of 4 parent education sessions over the six month period.
Parent/Guardian Signature: ____________________________ Date: ___________
Please Complete One for Each Participating Child
Child’s Name: ____________________________________________________________ 1. List any food allergies:
________________________________________________________________________ 2. List any medication allergies:
_________________________________________________________________________
3. List any other allergies:
_________________________________________________________________________ 4. List any medical conditions our staff should be aware of:
_________________________________________________________________________ 5. Does your child have Epilepsy/Seizures: ☐Yes ☐No
6. Does your child carry or need an epi-pen for an allergy?: ☐ Yes ☐No
If yes, I give my permission for Jacob’s Ladder staff to administer Epi-Pen _________ Initial 7. List any medications your child is currently taking:
_________________________________________________________________________ 8. Use the following key for grading level of supervision required for each task listed:
I = Independent S = Some Supervision C = Constant Supervision P = Physical Assist ____ Diaper ____Toileting ____Feeding ____Medication 9. Briefly describe any behavioral issues or special care for your child our staff should be aware of:
____________________________________________________________________________ 10. List foods that should be avoided: ________________________________________________ 11. List food preferences: _________________________________________________________ I consent to Jacob’s Ladder Pediatric Rehab Center to provide Respite Care services to my child, which may include gross & fine motor activities, sensory program activities, group social activities, meal prep activities, quiet times and participation in snack and lunch time activities:
PERMISSION TO RIDE IN PRIVATE VEHICLE
I hereby give permission for my son/daughter, __________________________________ (Child’s Name)
To ride with an employee of Jacob’s Ladder to the Center on the following Respite Program Dates:
9/19, 10/17, 11/21, 12/19/2015, 1/16, and 2/20/2016
I waive any and all claims against Jacob’s Ladder Pediatric Rehab Center, its affiliates, the driver, and/or agents for injury or damage that may be sustained as a direct or indirect result of my child’s participation in this activity.
In the event of illness or injury to my child while on this travel/activity, I hereby give my consent for medical or dental care deemed necessary by the attending health care provider or dentist. My child may be examined and any necessary procedures (medical, dental or surgical), anesthesia, or diagnostic
procedures (lab or x-ray) may be performed under the supervision of a member of the hospital or medical office staff furnishing such services.
I further acknowledge that I am financially responsible for any medical, dental, ambulance or other health care expenses which might occur as a result of such illness or injury.
___________________________________________ ___________________ Signature of Parent/Guardian Date
___________________________________________ Print Name
