Child Application Form

Basic Information
Parent Name*
First Last
Address*
Street Address City State ZIP Code
Home Phone
Work Phone
Cell Phone
Parent's Email
Name of Child with Special Needs
First Last
Child's Date of Birth
MM slash DD slash YYYY
Child's Age
What is your child's diagnosis?
Allergies and Medications
Does your child have any allergies?
- Yes
- No
Please list in full
Is your child taking any medications?
- Yes
- No
Please list in full
Will any of these medications need to be administered while he/she is in our care?
- Yes
- No
Please explain in full
Are there any side effects we should be alerted to?
- Yes
- No
Please explain in full
Toileting
Does your child need assistance with toileting?
- Yes
- No
Please explain in detail about assistance your child needs
Does your child require diapers or other absorbant products?
- Yes
- No
Is your child potty trained?
- Yes
- No
Will your child inform us verbally if he/she needs to use the bathroom?
- Yes
- No
Please explain how he/she communicates toileting needs or how we recognize that need.
How can we best help your child with toileting needs?
Behavior
Does your child have any special fears?
- Yes
- No
What 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 these
Please describe these other behaviors
Please 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?
Communication
How does your child communicate wants/needs
- verbal
- nonverbal
- facial expression
- signs or gestures
- technology
- other
Please explain nonverbal or other communication
Please explain the most effective and beneficial methods for caregivers to communicate with your child.
Eating Preferences and Habits
May your child eat/drink snacks such as cookies and lemonade if provided?
- Yes
- No
Please list any foods to which your child has allergies or that you prefer him/her not have:
My child has difficulty swallowing..
- Yes
- No
Please provide details about swallowing difficulties
How does your child eat?
- My child self-feeds
- My child needs assistance
Please describe any feeding intervention needed
(such as altered textures, straw, cup, special equipment, special spoon, etc.)
Activities
How does your child best engage with others?
- 1 on 1
- Small Groups
What 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 Information
Please provide the following information about each of the child's siblings. Press (+) to add additional siblings.

Siblings

Click (+) to add additional rows

Name	Age	Gender	Special Instructions

To the Parent or Guardian
Please 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 Liability
Aaron’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 Agreement
Please type your full name in the box above.
Email
This field is for validation purposes and should be left unchanged.

A respite care ministry for families of special needs children.

Basic Information

Allergies and Medications

Toileting

Behavior

Communication

Eating Preferences and Habits

Activities

Sibling Information

To the Parent or Guardian

Release of Liability