Living Truth Church Respite Care Application

If you are interested in the respite care program, please fill out the form below as completely as possible. **If you have already completed this form for the LTC Access Ministry, please skip to the brief registration section to indicate that you would like to take part in the next respite.**

Form: Application for Respite Care
We are excited to learn more about your child, so we can match him or her with the right respite worker. Please complete this mandatory form.

Child's Name Birth Date
Address Parent Name(s)
Home Phone Email
Cell Phone Work Phone
Referral Source
What community agencies is your child involved with?
Who should we call in case you cannot be reached?
Phone Relationship
Primary Physician Address
Phone    
Any additional physicians or other clinicians and phone numbers?
Medical Insurance Policy Number
Hospital of Choice    


Medical History

Diagnosis of Disability Date of Diagnosis
Cause (if known)    

Significant Medical History (hospitalizations, surgeries, chronic illnesses, injuries, etc.)

Allergies (food, medicines, insects, etc.)
Is your child prone to respiratory ailments? If so, please describe.
Has your child had seizures in the last two years? If yes, when?
Types? Frequency?
Duration?    
What is the preferred caregiver response?
What cues does your child give when he or she is getting ill?
Prescription Drugs and Dosages:
How are medications given (whole, crushed, in fruit, etc.)?
Other medical problems:

Mobility

Please indicate which of the following your child does:
Sit unsupported
Crawl, creep, scoot, roll
Walk independently
Walk on uneven terrain
Use a wheelchair or stroller
Move his or her own motorized wheelchair
Move his or her own manually operated wheelchair


Equipment and Activities
What equipment is needed by your child while in respite care?
What does your child enjoy?
What makes your child laugh?
Does your child prefer soft or firm things?
What smells does your child like?
Does your child have a favorite movement (rocking, spinning, jumping, walking, rolling, etc.)?
Does your child have any favorite sounds, or is there a sound your child likes to make?
Does your child like looking at or playing with anything in particular?
What activities (reading, singing/music, arts and crafts, coloring, puzzles, water, sand play, etc.) does your child enjoy?
What are your child’s favorite books, stories, music, computer programs?


Speech Communications and Sensory Impairments

Which methods of communication does your child use?
Points to objects named
Uses generalized gestures or sounds
Uses sign language
Uses pictures or icons
Says single words or sounds
Says phrases or sentences
Can your child follow simple directions? Does your child understand abstract ideas?
Does your child have any sensory impairments?
Vision
Hearing
Touch (sensation)
Balance

Cognitive and Emotional Characteristics
Cognitive Function—Describe your child’s general development level.
Emotional Characteristics—Does your child have special behavior problems?
If so, what are the specific problems?
How are they handled?
What things are likely to distract, upset or frustrate your child?
How does he or she react when upset or frustrated?
What works to assist or comfort your child?
Does your child like to be cuddled or hugged?

Activities of Daily Living
Does your child need assistance with dressing?
Does your child eat independently or need assistance?
Can your child use a cup, spoon, fork and knife?
Is your child right- or left-handed?
What are your child’s favorite foods or snacks?
Does your child have a choking problem?
Does your child need assistance with toileting?
Does your child have occasional or frequent accidents?
Please describe How often?
Is your child in diapers all the time or use a catheter?    neither
Are there particular positions or activities to be avoided?
Is there anything else we should know about your child?


By checking this box, I confirm that I am the parent/legal guardian of the child named above and agree that I have answered all questions truthfully and to the best of my ability. This acknowledgment acts as my signature.

Date

Please submit the form using the button at the bottom of this page. Thank you!

Registration Section for Returning Families

Please only complete this section if this is not your first time registering your child for respite at LTC. Due to limited space, we are only able to serve 10 families at each respite (first come, first serve). Additional families will be added to a waiting list.

Yes, I would like to register my child for the next respite. Today's Date
Name Child's Name
Names of your child's siblings staying at respite
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