“Kids Our Kids” Respite Program For Special Families (K.O.K.)
Application for participation
Date of application/Renewal (circle one): ____/____/____
Child’s name (last)________________, (first)_______________, (middle)________________ (nickname)_____________
Birthday: ___/___/_____ Current age:______
State diagnosis or describe your child’s special needs:
__________________________________________________________________________________________________
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Current medications
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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Allergies: (food, latex, medications, insects, animals etc.) ___________________________________________________
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Parents name (mom)___________________ (dad)_____________________ (last)_______________________________
Address: ___________________________________________________ City:_________________ Zip:______________
Email:____________________________ Home phone:________________ Other (type________)__________________
Siblings:
Name:____________________ Birthdate:___/___/_____ Name:____________________ Birthdate:___/___/_____
Name:____________________ Birthdate:___/___/_____ Name:____________________ Birthdate:___/___/_____
In the event of an emergency, the following person may be called an is authorized to pick up my child(ren). A drivers
license will be required to establish identification must be provided before your child will be released.
Name:______________________ Relationship:_______________ Phone:______________ DL#:_________________
Name:______________________ Relationship:_______________ Phone:______________ DL#:_________________
Does your family receive respite outside the home? ______ Yes _______ No
How did you hear about K.O.K.?__________________________________________________________________
Vision: Normal Impaired Blind
Hearing: Normal Impaired Deaf Wears haring aides Cochlear implant
Motor: Head control Rolls over Sits Crawls Cruises Walks
My child uses: Braces Walker Wheelchair
Toileting skills: Toilets independently Needs help, volunteers can help by:________________________________
Potty trained, needs assistance Currently being potty trained Uses diapers
“Kids Our Kids” Respite Program For Special Families (K.O.K.)
Application for participation
Eating habits: No restrictions Can take nothing by mouth Soft foods only Bottle only
Specific requests:____________________________________________________________________
Sleeping habits: Likely to want to sleep before 10 p.m. crib Enjoys rocking Change to sleepwear
Communication, communicates with others using: Speech Words Gestures Phrases Sentences
Babbles sign language Other:___________________________________________________
Can understand what others say: All of the time Some of the time Most of the time
Behaviors: Outgoing Shy Responds well to correction Adapts to new situations well
Can be destructive Adapts to new situations with difficulty Hyperactive and/or ADD
Responds to correction with difficulty May attempt to run away
Sometimes hits, bites hurts self/others Sometimes threatens others
What behaviors may we see at K.O.K.?______________________________________________________________
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What is the most successful way to deal with this behavior?_________________________________________________
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What does your child enjoy? Music Art/crafts Sports Stories Board games Video games
Dress up Computer Independent play Other:____________________________________
What does your child not enjoy?_______________________________________________________________________
My child is comforted by?_____________________________________________________________________________
Is there anything else you wish to tell us about your child?___________________________________________________
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_______________________________________ ____/____/_________________
Parent signature Date
_______________________________________ ____/____/_________________
Volunteer director review Date
Fax to 888-433-3942, email to JJ@JJChapa.com