FacebookThis field is for validation purposes and should be left unchanged.Basic InformationParent Name(Required) First Last Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneParent's Email Name of Child with Special Needs First Last Child's Date of Birth MM slash DD slash YYYY Child's AgeWhat is your child's diagnosis?Allergies and MedicationsDoes your child have any allergies? Yes NoPlease list in fullIs your child taking any medications? Yes NoPlease list in fullWill any of these medications need to be administered while he/she is in our care? Yes NoPlease explain in fullAre there any side effects we should be alerted to? Yes NoPlease explain in fullToiletingDoes your child need assistance with toileting? Yes NoPlease explain in detail about assistance your child needsDoes your child require diapers or other absorbant products? Yes NoIs your child potty trained? Yes NoWill your child inform us verbally if he/she needs to use the bathroom? Yes NoPlease explain how he/she communicates toileting needs or how we recognize that need.How can we best help your child with toileting needs?BehaviorDoes your child have any special fears? Yes NoWhat are they and how do you best address them?Please explain any stressors/triggers for your child (physical/sensory/emotional)When under stress/anxious does your child exhibit any of the following behaviors: Runs away Hits others Hits self Bites others Bites self Becomes destructive to property Other None of thesePlease describe these other behaviorsPlease describe methods/techniques to redirect or calm your child as needed.Are there any special words that your child uses that may not be easily recognized?How do you tell your child to stop a behavior that you do not approve of?When your child gets upset, what helps calm him/her down?What is a good way to distract your child should he/she have a tantrum?Are there any particular routines that are helpful at naptime?What position is most comfortable for your child when he/she is napping?CommunicationHow does your child communicate wants/needs verbal nonverbal facial expression signs or gestures technology otherPlease explain nonverbal or other communicationPlease explain the most effective and beneficial methods for caregivers to communicate with your child.Eating Preferences and HabitsMay your child eat/drink snacks such as cookies and lemonade if provided? Yes NoPlease list any foods to which your child has allergies or that you prefer him/her not have:My child has difficulty swallowing.. Yes NoPlease provide details about swallowing difficultiesHow does your child eat? My child self-feeds My child needs assistancePlease describe any feeding intervention needed(such as altered textures, straw, cup, special equipment, special spoon, etc.)ActivitiesHow does your child best engage with others? 1 on 1 Small GroupsWhat activities do you do with your child, or what activities does your child enjoy when playing alone?What activities does your child like to do when playing with other children?Please describe motivations or rewards we can implement for your child.Sibling InformationPlease provide the following information about each of the child's siblings. Press (+) to add additional siblings.SiblingsClick (+) to add additional rowsNameAgeGenderSpecial Instructions Add RemoveTo the Parent or GuardianPlease make sure your provide a clean change of clothes, wipes, diapers, etc.If your child is to receive any medication while in our respite care, the prescription bottle must state the name of the medication and the patient’s name. It must clearly show the dosage time, frequency, and routine of administration. A start and end date (or ongoing) should be indicated.We cannot provide care for your child unless the original prescribed bottle is provided.The child’s name should be placed on every container of medicine to be provided and initialed by the parent/guardian.All medications should be placed in a zip locked bag with your child’s name clearly written on the outside.This also applies to over the counter medication.Release of LiabilityAaron’s Staff is a ministry that provides respite care services to children with special needs and disabilities. To the best of our ability, we promise to provide a safe, nurturing environment and ask that you provide us with the information we need to best minister to your child or family member.By signing this form, you acknowledge that you understand that:Neither Aaron’s Staff nor the facility at which care is offered provides a medical service.You have given us all pertinent information to care for your child or family member that will pertain to the time when he/she is on site.You will indemnify Aaron’s Staff, its personnel, and all volunteer respite care workers of Aaron’s Staff, the facility at which care is offered and its personnel from all liabilities in the event of an accident or unforeseen circumstances that might arise from the respite care evening.You agree to this release of your own free will and volition.Acceptance I have read, understood, and agreed to the information for the Parent or Guardian and the Release of Liability above.Affirmation of AgreementPlease type your full name in the box above.
