Rapid Respite Relief Registration Form

Please note: Your honest answers to the following questions are strongly encouraged. Your child or children will not be declined from participating in this program due to your responses. We welcome all children, no matter what end of the spectrum they are on. They are all Au-Tastic in our eyes and we look forward to serving them.

Number of Children Participating in Respite Program:*
Names, Ages & Sex of Child or Children Participating in Respite Program:*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Parent/Guardian/Caregiver:*
Phone Number you can be reached in the case of an emergency:*
Emergency Contact Name:*
Emergency Contact Relation to Child:*
Emergency Contact Phone Number:*
Email Address:*
Which respite care date are you registering for?*
Date Format: MM slash DD slash YYYY
We will serve food, snacks, water and juice during the respite care event. Does your child or children have any special dietary needs we should know about it? For example, “My child only eats gluten free foods. My child cannot have apple juice."*
Does your child or children have any known allergies? Latex gloves will be worn during meal and snack time as well as during diapering.*
Does your child have any limiting or life-threatening conditions we should know about it? For example: Asthma or a heart murmur. Respite care participants will engage in outdoor play on the playground and/or physical education activities such as kickball.*
Is there anything we should know about your child that will help us better accommodate your child during the respite care event? For example, "My child takes medication that may make him/her drowsy. I allow my son to stay on his device for several hours so if he doesn't want to play outside, allow him to continue on his device."*
A sensory room/quiet room will be available.
Is your child potty trained? If not, D.A.T.S.M.O.M. will not provide diapers/pull-ups. Please bring any toiletry supplies your child or children would need for the respite care event.*
What size T-shirt does your child wear? Youth sizes and Adult sizes are available.*
Is there anything we should be aware of or on alert about regarding your child? For example, your child wanders off, likes to pick door locks, may not alert someone when he/she needs to use the bathroom, engages in self-injurious behavior or hits/throws items at others, etc.*
If your child is non-verbal or has limited speech, does the child use visual aids or a communication device?*
D.A.T.S.M.O.M. will not administer any prescription medication.
D.A.T.S.M.O.M. suggest you bring a change of clothing for your children. Please clearly label all bags, electronic devices or toys your child may bring to the respite care event. D.A.T.S.M.O.M. or the respite care host site will not be responsible for any lost, damaged or stolen personal items you or your children bring to the respite care event. Cots will be available for napping, should some children need and/or request a nap. Pillows and blankets will not be available. You are welcome to bring pillows and blankets for your child or children.

Disability as an Ability Toward Success: Moms on the Move

Rapid Respite Relief Registration Form

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