Special Needs Respite on February 9, 2020

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Afternoon programming for children and young adults with special needs (and their siblings) on February 9 from 12:30-4:00 pm

Email *

Name of person with special needs *

Age range of person with special needs *

newborn to 1 year old

2-4 years old

5-7 years old

8-10 years old

11-13 years old

14-18 years old

18+ (i.e. Young Adult)

Brief description of person's special needs (including any allergies or environmental sensitivities) *

Siblings of person with special needs who will attend the respite (if none, put N/A) *

Ages of any siblings attending listed with their names (if applicable)

Parent(s)/Guardian(s) Name(s) *

Emergency Contact Number (of parent or guardian) *

Required Form

I understand that by checking this box I am agreeing to fill out and return the Medical Form posted at https://www.fairview-umc.org/special-needs. It does NOT have to be notarized UNLESS I wish for the staff to have medical decision making power beyond calling 911

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