Jacob s Ladder Pediatric Rehabilitation Center, Inc. Child Respite Program

Transcription

1 Page 1 of 5 Intake Sheet 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: Father/Mother/Guardian: Home Address: City: State : Zip: Home Phone: Cell Phone: Employer: Address: Phone: Father/Mother/Guardian: Home Address: City: State : Zip: Home Phone: Cell Phone: Employer: Address: Phone: Emergency Contact Person: 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 I understand that a picture(s) may be taken of my child(ren). I hereby assign and authorize Jacob s Ladder the right (all rights) in and to such pictures. I also authorize Jacob s Ladder, without limitation, the right to reproduce, copy, exhibit, publish or distribute any such picture, and waive any rights or claims I may have against Jacob s Ladder and/or any affiliates or subsidiaries except as outlined in this contract. Initial By signing below, I am acknowledging that I have read and understand the policies, general information, Liability Waiver, and Photo Release outlined above. Parent/Guardian Signature Date:

2 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 must commit to bringing 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 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 available an epi-pen for an allergy?: Yes No If yes, are they able to administer on their own?: Yes No 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 needed C = Constant supervision required 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 Page 4 of 5 Jacob s Ladder Pediatric Rehab Center PERMISSION TO RIDE IN PRIVATE VEHICLE I hereby give permission for my son/daughter, (Child s Name) to ride with to the (Driver s Name) (Activity) at on (Location of Activity) (Date) 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. I understand that in the event of illness or injury to my child, responsible effort will be made to contact me. Best Number to Call: Cell Home Work Other Phone Numbers: Cell Home Work Other Signature of Parent/Guardian Print Name Date

5 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/film taking that MAY/MAY NOT be used on our, brochures, newsletters, and Jacob s Ladder Website. If I do not want any photos on the website for any reason, I understand that Jacob s Ladder will gladly remove it as soon as possible. I DO NOT authorize Jacob s Ladder Pediatric Rehab center to photograph my child(ren). Child s Name Parent/ Guardian Signature Date