Dear Families,
We are excited to provide respite care services for families with special needs children. To assist us in offering the best care, please fill out the registration form. This will help us understand your child's unique needs and ensure a secure and enjoyable experience for everyone involved.
Parent/Guardian Information
Full Name:
Relationship to Child:
Contact Number:
Email Address:
Emergency Contact (Name and Phone Number):
Child Information
Child's Full Name:
Child's Age:
Child's Date of Birth (MM/DD/YYYY):
Gender: Select one... Male Female Special Needs Information Diagnosis/Disability: Functional Level (e.g., mild, moderate, severe): Mobility (e.g., independent, uses assistive devices, requires assistance): Allergies (if any): Dietary Restrictions (if any): Communication and Behavior Preferred communication method (e.g., verbal, sign language, AAC device): Known triggers (if any): De-escalation techniques (if any): Preferred activities and interests: Medical Information Doctor's Name: Doctor's Contact Number: List any current medications and dosages: Additional Information Please provide any other relevant information that will help us create a positive and supportive environment for your child: Consent and Liability Release By submitting this form, I, acknowledge that the respite care services provided by the Malaikah Foundation during the event are voluntary and extended as a courtesy Parent/Guardian Signature: Date: Thank you for registering for our respite care services. We look forward to providing a safe and enjoyable experience for your child.
Sincerely, The Malaikah Foundation