New Customer Registration Form (Child)

Application for Respite Care
Child's Name

First NameLast Name
Date of Birth
Age
Parent/Caregiver 1 Name

First NameLast Name
Parent/Caregiver 2 Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number*

Area CodePhone Number
E-mail*
Cell Phone (Parent 1)
Cell Phone (Parent e)
Preferred Contact
(i.e. Phone, Text, Email, etc...)
Which Parents' Night Out location would you prefer to attend?

New Providence Baptist Church, ForsythBibb Mt. Zion Baptist Church, Macon
Emergency Contact

First NameLast Name
Relationship to Child
(i.e. Mother, Grandfather, Foster, God-parent,etc...)
Phone Number

Area CodePhone Number
Primary Physician
Phone Number

Area CodePhone Number
Hospital of Choice
Diagnosis of Developmental Disability (Anchor of Hope reserves the right to ask for proof this diagnosis)
Allergies (food, medicines, insects, etc.)
Is your child prone to respiratory illnesses?

YesNo
If yes, please describe.
Has your child had seizures in the past 2 years?

YesNo
Duration?
Frequency?
Types?
What is the preferred caregiver response?
What cues does your child give when he or she is feeling ill?
Is your child taking any prescription drugs? If so, please list types and dosages.
How are medications given? (i.e. whole, crushed, in fruit, etc.)
Any other medical concerns or problems?
Please indicate which of the following your child does

Sits unsupprtedCrawl, creep, scoot, rollWalk independentlyWalk on uneven terrainUse a wheelchair orstrollerMove his or her ownwheelchair?
If your child uses a wheelchair, what type is it?

MotorizedManual
What equipment is needed by your child while in respite care?
Does your child have a favorite movement? (i.e. rocking, spinning, jumping, walking, rolling, etc.)
Does your child have a favorite sound to hear or a favorite sound to make?
Are there any activities your child especially enjoys (reading, swinging, coloring, music)? Does your child like looking at or playing with anything in particular?
Which methods of communication does your child use?

Points to objects namedUses generalized gesturesor soundsUses sign languageUses pictures or iconsSays single words or sounds
Does your child follow simple directions?

YesNo
Does your child understand abstract ideas?
Does your child have any sensory impairments?

VisionHearingTouch & SensationBalanceSensitive toloud noises, music, etc?
Cognitive Function - Please describe your child's general developmental level:
Emotional Characteristics - Does your child have any specific behavior problems?
If yes, how are they handled?
What things are likely to upset, distract, 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 need assistance with dressing?

YesNo
Does your child need assistance eating?

YesNo
Can your child use a cup, fork, knife, and spoon?

YesNo
What are your child's favorite foods or snacks?
Are there any foods your child cannot have?
Does your child have a choking problem?

YesNo
Does your child need assistance with tolieting?

YesNo
Does your child have occasional or frequent accidents?

YesNo
If yes, please describe:
Does your child wear diapers or have a catheter?

YesNo
Are there particular positions or activities to be avoided?
Is there any other information we should know about your child?
Sibling 1

First NameLast Name
Age
Date of Birth
Sibling 2

First NameLast Name
Age
Date of Birth
Sibling 3

First NameLast Name
Age
Date of Birth
Sibling 5

First NameLast Name
Age
Date of Birth
Sibling 6

First NameLast Name
Age
Date of Birth
Any allergy concerns of siblings?
I give Anchor of Hope Foundation permission to take/use photos of my family during Parents' Night Out and other Special Needs ministry events for promotional purposes (print, web, or brochures).

YesNo
I give Anchor of Hope Foundation Permission to use my child's first name and stories of my child for promotional purposes (print, web, or brochures) in order to communicate to donors how their support is making an impact.

YesNo
How did you hear about us?
Signature of Parent or Guardian (by typing my name I signify it to be my legal signature)

First NameLast Name
Please Note Our Parent’s Night Out Sick Child Policy

This policy has been written in order to promote the good health of the staff, volunteers, and children in our care. Your child will not be permitted to attend Parent’s Night Out if they have any of the following:

•         Persistent fever (free of fever for 24 hours)

•         Flu-like symptoms

•         Any symptom of childhood diseases such as scarlet fever, German measles, mumps, chicken pox, or whooping cough

•         Excessive runny nose (due to illness)

•         Severe cough or difficulty breathing

•         Vomiting (or have vomited within the last 24 hours)

•         Excessive diarrhea (or have had excessive diarrhea within the last 24 hours)

•         Contagious rashes

•         Conjunctivitis (pink, red, or swollen eyes)

•         Lice

•         Other contagious conditions
By Signing here, you agree to follow and adhere the Terms and Conditions stated above in our Sick Child Policy.

First NameLast Name
Date

MonthDayYear
Date
Release of Liability:

I certify that I have answered the above questions truthfully and have not withheld any information relevant to my application. I give consent for my child to participate in Anchor of Hope Foundation's Parents Night Out respite program at New Providence Baptist Church and/or Bibb Mount Zion Baptist Church. If my child suffers an injury or illness while participating in this respite program, and if respite volunteers of Anchor of Hope Foundation are unable to contact me at the telephone numbers listed above, I hereby authorize the respite volunteers of Anchor of Hope Foundation to obtain such emergency medical care or treatment as the medical volunteers of Anchor of Hope Foundation deem necessary. I further consent to the provision to my child of such emergency medical care or treatment, as is deemed reasonably necessary by a licensed physician. This consent is signed for the purpose of authorizing medical treatment under emergency circumstances in my absence.

I, on behalf of my child, hereby release and waive any and all claims for damages, injury, illness, or death against either Anchor of Hope Foundation or New Providence Baptist Church or Bibb Mount Zion Baptist Church, including their officers, directors, employees, agents, independent contractors, and staff (collectively "Parents’ Night Out Releasees”) that may accrue to me or my child as a result of my child’s participation in the Parents’ Night Out respite program, and agree to indemnify, protect, and hold harmless the Parents’ Night Out Releasees from any claim or liability whatsoever, including, but not limited to, personal injury, property damage, court costs, and attorney’s fees, however caused, as a result of my child’s participation in the Parents Night Out respite program, except for conduct constituting gross negligence by Parents’ Night Out Releases.

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.
By Signing here, you agree to follow and adhere the Terms and Conditions stated above in our Release of Liability Policy.

First NameLast Name
Date

MonthDayYear
Date
In consideration of my child's participation in the Anchor of Hope Parent's Night Out Program, I acknowledge and agree to the following:

I am aware of the existence of the risk on my physical appearance to the venue and my child's participation to the activity of the Organization that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.

My child has not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.

My child, nor any member(s) of my household, traveled by sea or by air, internationally within the past 30 days.

My child, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days.

I recognize that my child may be in any case be at risk of contracting COVID-19.

With full knowledge of the risks involved, I hereby release, waive, discharge Anchor of Hope Foundation, New Providence Baptist Church, and/or Bibb Mount Zion Baptist Church, its board, officers, independent contractors, affiliates, employees, representatives, successors, assigns, and from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by my child related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.

I agree to indemnify, defend, and hold harmless Anchor of Hope Foundation, New Providence Baptist Church and/or Bibb Mount Zion Baptist Churchfrom and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.
By Signing here, you agree to follow and adhere the Terms and Conditions stated above in our COVID Release of Liability Policy.

First NameLast Name
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Application for Respite Care