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Respite Co-op Parent Information
Name
E-mail Address
Best Contact Telephone Number
Child's Disability
Child's Age
Child's Sex
Male
Femaile
Sibling's Age(s)/Sex
2nd/3rd Special Needs Child's Age
2nd/3rd Child's Diability or Medical Conditions
Times respite care is needed (check all that apply)
Before School
During the Day (for children not in school)
After School
Weeknights
Weekend Days
Weekend Nights
Overnight
Summertime Days
Occasionally--Various Times
Location where care for your child(ren) could be given (ck all that apply)
Your Home
Other Family or Provider's Home
Daycare Center/3rd Party Facility
Times you can provide respite care for another family (ck all that apply)
Before School
During the Day (for children not in school)
After School
Weeknights
Weekend Days
Weekend Nights
Overnight
Summertime Days
Occasionally--Various Times
Maximum number of people for which you could provide care (not including your own)
1
2
3
4+
Ages for which could you provide care (ck all that apply)
Infant
Toddler
Elementary age
Middle School age
High School Age
Adult
No preference--I can take them all.
Location where you could provide care (ck all that apply)
Your Home
Other Family's Home
City in which you reside
Do you have pets?
Yes
No
List any specialized equipment/facilities at your home (e.g. ramp, pool, trampoline, adaptive bikes, etc.).
Please provide any additional necessary information not covered above
By submitting this form, you are giving your permission to have your information published in a database for the purpose of providing parents an opportunity to swap respite hours with other parents.
I agree
I disagree
