Respite Application

Play-Place Respite Program Application

Play-Place Respite Program Application

Attendee’s Name
Attendee's Name
First
Last
Sex

Please Select the session slots below:

I am applying to:

Discounts

2nd child – $60 (20% off)

Paid in Full

Sessions run Friday through Sunday and cost $75/session ($15/hour)

Session Fees: To be paid in total daily. Secure your child’s placement.

All payments for all registered session are to be paid in full at time of drop-off unless contracted otherwise.

Emergency Contact Information

Emergency Contact 1:

Name
Name
First
Last

Emergency Contact 2:

Name
Name
First
Last

Medical Information:

Parent Questionnaire

Client Name
Client Name
First
Last

My child:

1. Prefers to do things with others. than on his/her own
2. Is your child verbal?
3. Gets upset when he/she can’t pursue interests
4. Does not get upset if daily routine is disturbed
6. Has a diagnosis of schizophrenia, ADHD, bipolar, or similar disorders
7. Has routines or rituals that must be completed
8. Joins in playing games with others easily
9. Has hearing or visual difficulties
10. Is toilet trained
11. Seeks medical help when needed (i.e. recognizes own feelings of pain, discomfort, illness)
12. Responds appropriately to reasonable changes in routine.
13. Is impulsive?
14. Has temper tantrums in school/group setting.
15. Wanders or runs away at times.
18. Has the client received respite or CLS services before?
19. Does your child have a history of aggression towards others?
20. When client received services, what was the ratio of client/direct care technicians?
21. What problematic behaviors need to be addressed during service?

Photo/Video Release

I hereby authorize Play–Place Autism & Special Needs Center to use:
My child’s image may be used for:

Any and all forms and media including without limitation use on the World Wide Web now or hereafter, and for any purpose whatever including without limitation illustration promotion, publicity, art, education, advertising, trade, fundraising, and if appropriate, to use my name, pertinent education and/or biographical facts

Limitations

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