Respite Event Enrollment – Disability Services

Step 1 of 2

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Participant and Family Information

Participant's Name

Date of Birth

MM slash DD slash YYYY

Home Phone Number

Participant's Home Address

Street Address City State ZIP Code

Name(s) of Parent(s) and/or Guardian(s)

Address (if different from Participant)

Street Address Address Line 2 City State ZIP Code

List telephone numbers where parent or guardian may be reached while participant is at Saturday Fun

List name and phone number of person(s) to call in case of emergency if parent/guardian can't be reached

I hereby authorize the following persons to pick up participant. Participant will only be released to a person designated by the parent/guardian after verification of ID

Name

Phone

Participant Diagnosis and Needs

What is participant's diagnosis?

Does participant have any allergies?

Yes

Please list and describe any allergic reaction:

Will participant need to take any medication while at Sat. Fun?

Yes

Please complete a Medial Authorization Form

Does participant need assistance with toileting?

Yes

Please describe the assistance required:

What would be appropriate staff ratio for participant?

1:1 * (1:1 support may be limited. Please confirm availability at least 48 hours prior to the event.)

1:2

1:3

1:4

Authorization for Emergency Medical Attention

I give consent for Laura Baker Services Association to secure any and all necessary emergency medical care for participant, including transport to the nearest hospital for emergency services.

Signature of Parent/Guardian

Date

MM slash DD slash YYYY

Name of Primary Care Physician

Phone Number

Please continue to page 2 to list any additional information, including behavior modifications, that will assist us in supporting participant.

How does participant best communicate?

How does participant typically express dislikes/frustration/fear? Is there any body language we can look for that indicates participant is stressed or frustrated?

Please list types of situations (or triggers) that cause increased stress or anxiety for participant, as well as the strategies that help decrease stress or anxiety.

Has participant ever been arrested, suspended from school, or sent home from school for behavioral problems?

Yes

Please Explain

Does participant have a behavior plan at school?

Yes

Please provide a copy of the behavior plan.

Potential Challenging Behavior (check all that apply)

Pinches

Sometimes

Often

Hits

Sometimes

Often

Bites

Sometimes

Often

Scratches

Sometimes

Often

Withdraws

Sometimes

Often

Fights

Sometimes

Often

Runs away/elopes

Sometimes

Often

Damages Property

Sometimes

Often

Other (please explain and indicate sometimes or often)

What proactive strategies help participant to stay calm when he/she becomes frustrated, stressed or angry?

Schedules

Walks

Movement Break

Time away from group

Drawing or writing process

Other

Indicate other strategies

Where did you hear about Saturday Fun?

LBSA’s Saturday Fun is not a state licensed respite service. The program is staffed largely by volunteers and is not equipped to handle aggressive or dangerous behavior. If participant has exhibited aggressive behavior in the last 12 months, please indicate when, where and under what circumstances the aggression occurred. The Family Support Services Coordinator will contact you to discuss the circumstances of the incident. If participant exhibits aggressive or dangerous behavior while at Saturday Fun, a parent or guardian will be contacted to pick up participant immediately.

* 1:1 staff support limited. Please confirm availability at least 48 hours prior to event.

Phone

This field is for validation purposes and should be left unchanged.

Enroll for Respite Events

Participant and Family Information

Participant Diagnosis and Needs

Authorization for Emergency Medical Attention