Jacob s Ladder Pediatric Rehab Center: Respite Program Intake Packet Page 1 of 5. Respite Program:

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1 Jacob s Ladder Pediatric Rehab Center: Respite Program Intake Packet Page 1 of 5 Respite Program: Child s Name #1 Age Birth Date Grade: School: Sex: M F Diagnosis/Disability: Child s Name #2 Age Birth Date Grade: School: Sex: M F Diagnosis/Disability: Emergency Contact #1: Relationship to Child: Home Address: City: State : Zip: Home Phone: Cell Phone: Employer: Address: Phone: Emergency Contact #2: Relationship to Child: Home Address: City: State : Zip: Home Phone: Cell Phone: Employer: Address: Phone: Child s Physician: Phone Number: Waiver of participation and release of liability: As a condition of participation in the program, I waive any and all claims against Jacob s Ladder Pediatric Rehab Center, its affiliates and/or agents for injury or damage that may be sustained as a direct or indirect result of my child s participation in program activities. Initial I give my consent to his/her being administered any emergency medical treatment by a physician or hospital in case of an accident or illness. Initial By signing below, I am acknowledging that I have read and understand the policies, general information, and Liability Waiver outlined above. Parent/Guardian Signature Date:

2 Jacob s Ladder Pediatric Rehab Center: Respite Program Intake Packet Page 2 of 5 The following information is necessary for our records and the funding our organization receives. Jacob s Ladder depends upon outside funding to develop and sustain programs offered to its participants. Therefore your cooperation in providing this information is greatly appreciated. The answers you provide are confidential. Ethnicity/Race (check only one): African American Caucasian/White Hispanic/Latino Asian Native American Other: Primary Language (check only one): English Spanish Other: Family Income Level (Check only one) Under $10,000 $10,000 $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $69,999 $70,000 - $79,999 $80,000 - $89,999 $90,000 - $99,999 $100,000 or higher Does anyone in your household receive one or more of the following (check all that apply): Free or reduced price lunch at school Food stamps Supplemental Security Income (SSI) Medicaid How did you hear about the Jacob s Ladder Respite Program? I understand that in order for my child to participate in the respite program that: 1. I will bring my child to each of the six (6) Saturdays over the six month period. 2. I agree to pay $20.00 for each of the six (6) Saturdays. 3. I will participate in a minimum of 4 parent education sessions over the six month period. Parent/Guardian Signature: Date:

3 Jacob s Ladder Pediatric Rehab Center: Respite Program Intake Packet Page 3 of 5 Please Complete One for Each Participating Child Child s Name: 1. List any food allergies: 2. List any medication allergies: 3. List any other allergies: 4. List any medical conditions our staff should be aware of: 5. Does your child have Epilepsy/Seizures: Yes No 6. Does your child carry or need an epi-pen for an allergy?: Yes No If yes, I give my permission for Jacob s Ladder staff to administer Epi-Pen Initial 7. List any medications your child is currently taking: 8. Use the following key for grading level of supervision required for each task listed: I = Independent S = Some Supervision C = Constant Supervision P = Physical Assist Diaper Toileting Feeding Medication 9. Briefly describe any behavioral issues or special care for your child our staff should be aware of: 10. List foods that should be avoided: 11. List food preferences: I consent to Jacob s Ladder Pediatric Rehab Center to provide Respite Care services to my child, which may include gross & fine motor activities, sensory program activities, group social activities, meal prep activities, quiet times and participation in snack and lunch time activities: Parent/Guardian Signature: Date:

4 Jacob s Ladder Pediatric Rehab Center: Respite Program Intake Packet Page 4 of 5 PERMISSION TO RIDE IN PRIVATE VEHICLE I hereby give permission for my son/daughter, (Child s Name) To ride with an employee of Jacob s Ladder to the Center on the following Respite Program Dates: 9/19, 10/17, 11/21, 12/19/2015, 1/16, and 2/20/2016 I waive any and all claims against Jacob s Ladder Pediatric Rehab Center, its affiliates, the driver, and/or agents for injury or damage that may be sustained as a direct or indirect result of my child s participation in this activity. In the event of illness or injury to my child while on this travel/activity, I hereby give my consent for medical or dental care deemed necessary by the attending health care provider or dentist. My child may be examined and any necessary procedures (medical, dental or surgical), anesthesia, or diagnostic procedures (lab or x-ray) may be performed under the supervision of a member of the hospital or medical office staff furnishing such services. I further acknowledge that I am financially responsible for any medical, dental, ambulance or other health care expenses which might occur as a result of such illness or injury. Signature of Parent/Guardian Date Print Name

5 Jacob s Ladder Pediatric Rehab Center: Respite Program Intake Packet Page 5 of 5 Photograph/Media Authorization I authorize Jacob s Ladder Pediatric Rehab Center to photograph my child(ren). I give permission for my child to be included in picture/video recording that may be used on our brochures, newsletters, Donor Thank You s, and Jacob s Ladder s Website. I DO NOT authorize Jacob s Ladder Pediatric Rehab center to photograph my child(ren). Child s Name Parent/ Guardian Signature Date

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