Name
*
First Name
Last Name
Email Address
*
Date
*
MM
DD
YYYY
How did you hear about All in Need?
Child's Full Name
*
First Name
Last Name
Would you like to use your respite hours for Revive?
Child's Diagnosis
*
Is your child receiving respite care from other agencies?
Is your child a Regional Center client?
Please tell us who your Regional Center Case Manager is, if applicable.
What is your case manager's phone number? If applicable.
(###)
###
####
What is your case manager's email? If applicable.
Grade Level
Age
*
Sex
Male
Female
Birthdate
*
MM
DD
YYYY
Mailing Address
*
Home Phone
(###)
###
####
Mobile Phone
*
(###)
###
####
Physician's Name
*
Physician's Phone
*
(###)
###
####
Physician's Address
*
Health Insurance Provider
*
Policy Number
*
Allergies / Special Health Concerns
*
Child's Positive and Negative Behaviors
What methods are used at home to deal with these behaviors?
Child's Likes
Child's Dislikes
Child's Triggers (Set Offs)
*
Level of Supervision Needed
What negative behaviors should we be aware of?
Does your child have any of the following?
Check all that apply
Medications required to be administered while attending AiN?
*
Does your child communicate using any of the following?
*
Check all that apply
Please elaborate. Can child make his / her needs known?
Can your child?
Check all that apply
What are the approximate grade levels for each of the above skills?
Do both parents live with the child?
Mother's Name
First Name
Last Name
Address, if different than Child's
Mother's Phone
(###)
###
####
Mother's Email
Father's Name
First Name
Last Name
Address, if different than Child's
Father's Phone
(###)
###
####
Father's Email
Do you need additional care for siblings - ages 3 through 5th grade?
Emergency Contact (other than parents)
*
First Name
Last Name
Relationship to Child
*
Address
*
Phone
*
(###)
###
####
Secondary Emergency Contact (other than parents)
*
First Name
Last Name
Relationship to Child
*
Address
*
Phone
*
(###)
###
####
Name of Hospital / Clinic Preference
*
Hospital / Clinic Phone
*
(###)
###
####
Do you have a Do-Not-Resusitate (DNR) for this child?
*
I hereby give permission to All in Need, Family Support to use photographic, video, or digital images in which I and/or my child(ren) may appear in publications used for the purpose of advertising and public relations. I understand that I will receive no payment for the use of images in which I and/or my child(ren) appear.
*
Please indicate that you have read and agree to the terms presented in the Terms and Conditions agreement.
*
I authorize all medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent.
*
First Name
Last Name
I release All in Need, Family Support and individuals from liability in case of accident during activities related to All in Need, Family Support as long as normal safety procedures have been taken.
*
First Name
Last Name
Date
*
MM
DD
YYYY
Additional Comments
