Respite Event Questionnaire
We are so glad that you are able to attend our respite event at CSBF! Please fill out this form so that we know how to best serve you and the person who will be attending the event. 
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Correo electrónico *
Name *
Date of Birth *
DD
/
MM
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Age *
Diagnosis *
Emergency Contact #1:
(please provide a name, phone number and e-mail address) 
 *
Emergency Contact #2:
(please provide a name, phone number and e-mail address) 
 *
How does the person attending the respite event best communicate?  *
Does this person use any communication devices, gestures, or sign language?  *
If yes, please provide a brief description. 
Does the person attending the event have any physical limitations?  *
If yes, please provide a brief description. 
Does the person attending the event have any allergies or special dietary needs?  *
If yes, please provide a list of allergies and/or dietary needs. 
Does the person attending the event have any sensory needs (ex: quiet room, headphones, sunglasses?) *
If yes, please provide a brief description. 
Does the person attending the event have any behaviors?  *
If yes, please list behaviors, triggers, and ways to offer comfort for behaviors. 
Does the person attending the respite event have any restrictions or limitations of certain activities (ex: limited time on video games, movies etc.?) *
If yes, please provide a brief description. 
Do you give Curtiss Street Bible Fellowship permission to use photos or video for promotion?  *
Is there any other specific information that could be useful for us to provide the best possible Respite Care to your loved one? 
Se enviará un correo electrónico con una copia de tus respuestas a la dirección que suministraste.
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