Which Revive! Respite are you registering for?
Name (First Last)
Child's DOB
Sibling(s) attending respite (Please list name & age):
Parent/Guardian Name
Contact Number
Contact email
Who is authorized to pick up your child?
What are you child's likes/dislikes?
Please list any dietary restrictions your child has.
Please describe your child's diagnosis/mobility.
Does your child need assistance in toileting? If yes, please explain.
Does your child need assistance when eating? If yes, please explain.
Does your child or sibling(s) have any allergies, including food? If so, what are they, and what action is taken in the event of exposure (Epi-pen, call 911, etc.)?
Is there any additional information/comments you have about your child that would be helpful to us?
In case of an emergency, please list your Hospital preference.
By selecting 'yes' on this form, I give permission for my child/children to attend and participate in the respite night. I understand and authorize that my child/children's image may be photographed or filmed and used in church related video presentations, printed publications, or church website/social media. I also give my consent and authorization for emergency transportation and any medical treatment my child/children may require in the unlikely event my child/children is injured or becomes ill while attending an event at Richland Creek Community Church.
  • Yes
  • No