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We are so excited to enjoy your child at BREATHE Special Needs Respite!
In order to ensure your child has the best experience possible, please answer the following questions. This will help our volunteers understand your child better and ensure they have an excellent experience.

Thank you for using BREATHE Special Needs Respite. We hope you have a great evening out on the town!

Have you already filled out the main form in the past?
Click HERE to fill out a Recurring Families form.

*Please Note:
Be sure to fill out a SEPARATE FORM for each Special Needs child.

Contact Information
(*) denotes a required field
Parent/Caregiver Name*
FirstLast
Email*
Address*
Street AddressCityStateZip Code
Phone*
{###)###-####
Child Information (Special Needs)
Name*
FirstLast
Date of Birth*
Child Information (Siblings)
For Each "Non Special Needs" Child
Be sure to fill out a SEPARATE FORM for each Special Needs child.
Add Names, Birth Dates and anything special that we should know to help make your child's night fun.
Breathe Event Selection
Select BREATHE Event (Select all that apply)*
- February 17th
- March 16th
Questions
Please answer all questions to the best of your ability.
1. Does your child have any food allergies? If so, please explain.*
2. We want your child to have a wonderful experience with us! We realize that at times kids can become over stimulated or require some redirection. What words or gestures do you use to redirect?*
3. Are there any behaviors/symptoms staff should be aware of in order to provide the best care for your child? (i.e. child may seem distant before a seizure, etc.)*
4. Please give us the name and contact information for your child’s physician in the event of an emergency.*
5. Here is your chance to dote on your kids! Tell us all the fun stuff – favorite hobbies, animals, colors, favorite friend, what do they do best? This info helps volunteers break the ice!*
6. In order to make sure we can reach you, we ask all participating families to have a cell phone with them during BREATHE. Could you please provide the number(s)?*
7. What tasks (if any) does your child require additional assistance with? (i.e. going to the bathroom, eating, etc.) What does that assistance look like?*
8. Is your child verbal? If not, are there any methods being used to facilitate communication? (i.e. sign language, dynavox, boardmaker, etc.)*
9. Does your child have a set behavior plan we should be aware of such as a bathroom schedule?*
10. Please describe any special needs or requirements your child may have so that we know how to better serve them.*
Any Additional Information
Anything else we need to know? Tell us below.
More Information Here
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THE NEXT STEP: Join us at Breathe!

After completing this form, you will receive an email regarding your registration. You do not need to respond to this, for it is our way of thanking you for your willingness to be a part of Breathe.

Respite for parents of kids with special needs.

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Contact Information

Child Information (Special Needs)

Child Information (Siblings)

Breathe Event Selection

Questions

Any Additional Information