If you have a child with special needs and would like to apply for our program, please fill out the annual enrollment form below.

Please also submit a copy of the doctor’s note or a current copy of the IEP, or other forms showing child’s eligibility. Once we receive your enrollment form, we will set up a phone interview with the family. You will receive a PayPal invoice for $60 for our enrollment fee. The fee with be waived if you sign up for our annual membership.


membership Enrollment Form

Note: This form includes a photo release. Please review our Terms & Conditions before your apply.

Name *
Name
Date *
Date
Child's Full Name *
Child's Full Name
Would you like to use your respite hours for Revive?
Is your child receiving respite care from other agencies?
Is your child a Regional Center client?
What is your case manager's phone number? If applicable.
What is your case manager's phone number? If applicable.
Child's Information
Grade Level
Birthdate *
Birthdate
Home Phone
Home Phone
Mobile Phone *
Mobile Phone
Physician's Phone *
Physician's Phone
What methods are used at home to deal with these behaviors?
What negative behaviors should we be aware of?
Medical / Health Considerations
Does your child have any of the following?
Check all that apply
Medications required to be administered while attending AiN? *
Child's Method of Communication
Does your child communicate using any of the following? *
Check all that apply
Child's Education Skills
Can your child?
Check all that apply
Parent's Information
Do both parents live with the child?
Mother's Name
Mother's Name
Mother's Phone
Mother's Phone
Father's Name
Father's Name
Father's Phone
Father's Phone
Do you need additional care for siblings - ages 3 through 5th grade?
Emergency Contact
Emergency Contact (other than parents) *
Emergency Contact (other than parents)
Phone *
Phone
Secondary Emergency Contact (other than parents) *
Secondary Emergency Contact (other than parents)
Phone *
Phone
Hospital / Clinic Phone *
Hospital / Clinic Phone
Do you have a Do-Not-Resusitate (DNR) for this child? *
Photo Release
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. *
Digital Signature
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. *
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.
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. *
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.
Date *
Date