Spring Break Respite Care
Participant Application Form

We are delighted you are interested in participating in our event! Fill out the form below and we will be in touch!

The non-required fields are for new participants or if you would like to update information from previous respites.

Family Contact Information

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child Information

Name

First Name

Last Name

Date of Birth

YYYY

Gender

Disability(s)

(If more than one, please separate with a comma)

Important Information About Disability

Languages other than English

Healthcare Information

Allergies (food, seasonal, etc.)

Treatment for Allergies

Dietary Restrictions

Medications

Mobility Needs

Other Specific Accommodations Needed

Auditory/Visual Needs

Toileting/Diapering Needs

Insurance Provider and Insurance Number

Doctor Name and Phone Number

Behavioral Information

Communication Ability

Things the participant does like:

Things the participant does not like:

Signs that the participant is getting upset:

Behavior concerns:

My parent/caregiving wants to know when:

Does the participant need extended care? (3:00-5:00PM)

Yes

Permissions:

(By checking these boxes you confirm you have read the consent forms linked below this form and give your consent.)

Participant Consent

Media Consent

Emergency Contacts

Contact 1

First Name

Last Name

Phone

(###)

###

####

Contact 2

First Name

Last Name

Phone

(###)

###

####

Any additional information about the participant:

*Please read the Participant Consent and Media Consent.

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910A Catlett Road
Canton, MS 39046
601-594-0148

PARTNER

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Careers

Quiet Waters is a non-profit, 501(c)3 Christian ministry. All gifts to Quiet Waters are tax deductible, less goods and services received. Tax-ID# 26-1570909.

Spring Break Respite CareParticipant Application Form

FIND US

PARTNER

Spring Break Respite Care
Participant Application Form