Participant Registration

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Please join us on Saturday, February 18th, from 5-7pm for Revive! Respite. This event is open to participants (ages birth through adult) with special needs and their siblings within our community. Families do not need to be members or regular attenders of Richland Creek to participate.

Participants First and Last Name *

Participants Date of Birth *

YYYY

Participants Age *

Will sibling(s) be attending? If so, please list name and ages.
*

Parent/Guardian Name *

Parent/Guardian Address *

Contact Phone *

Contact Email *

Who is Authorized to pick up your participant(s)? *

Do you have a home church? If yes, please list which church you attend.
*

Is this your first time attending Revive! Respite?
*

Yes

Participant's Diagnosis?
*

Does your participant or sibling(s) have food or other notable allergies? If so please explain what they are and what action is taken in the event of an exposure (epi-pen, call 911, etc.)?
*

Will your participant or sibling(s) be bringing emergency medication? (epi-pen, inhaler, etc.) If so, please explain with medication name and instructions.
*

Does your participant or sibling(s) have any other food restrictions or require assistance with eating? If so, please explain.
*

Does your participant require assistance with toileting? If so, please explain.
*

Does your participant communicate needs/wants verbally or do they require additional support (i.e. communication device, etc.)? Please explain.
*

Describe any activities and interests your participant enjoys.
*

What are your participant's dislikes? (i.e. loud noises, etc.)
*

My participant shows the following signs when he/she is stressed, overwhelmed and/or needs a break:
*

Strategies that help my participant regroup and feel safe are:
*

Any additional info about your participant that would be helpful to us?

I give permission for my child(ren) to attend and participate in Revive! Respite. I understand and authorize that my child's image may be photographed or filmed and used in church related video presentations, printed publications, or church website/social media.
*

Yes

I give my consent and authorization for emergency transportation and any medical treatment my student(s) may require in the unlikely event my student(s) is injured or becomes ill while attending Revive! Respite at Richland Creek Community Church.
*

Yes

Hospital Preference in the event of an emergency?
*

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