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Embrace / NightOWLS Family Application
Family Information
Family Name
Name(s) and age(s) of each child who will be attending NightOWLS and/or Embrace events.
NightOWLS Families only: My family would like to attend NightOWLS
Friday evenings from 6:00-10:00pm
Saturday afternoons from 1:00-5:00pm
Child(ren) live(s) with
Both parents
Mother
Father
Other
Please provide additional information
Primary Parent/Guardian
Primary Parent/Guardian First Name
Primary Parent/Guardian Last Name
Primary Parent/Guardian Relationship to Child
Primary Parent/Guardian Email
Primary Parent/Guardian Phone Number
Primary Parent/Guardian Cell Phone Carrier (Ex. AT&T, Verizon)
Primary Parent/Guardian Address
Primary Parent/Guardian Apartment, suite, etc.
Primary Parent/Guardian City
Primary Parent/Guardian State
Primary Parent/Guardian Zip/Postal Code
Secondary Parent/Guardian
Secondary Parent/Guardian First Name
Secondary Parent/Guardian Last Name
Secondary Parent/Guardian Relationship to Child
Secondary Parent/Guardian Email
Secondary Parent/Guardian Phone Number
Secondary Parent/Guardian Cell Phone Carrier (Ex. AT&T, Verizon)
Secondary Parent/Guardian Address
Secondary Parent/Guardian Apartment, suite, etc.
Secondary Parent/Guardian City
Secondary Parent/Guardian State
Secondary Parent/Guardian Zip Code
Emergency Contact Person
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Relationship to Child(ren)
Emergency Contact Phone Number
Child:
Child Full Name
Child Preferred Name or Nickname
Child Birthdate
Child Age
Child Gender
Child: Does your child currently attend school?
Yes
No
Child: Name of school
Child: Grade in school
Child: Has your child been diagnosed with a disability or special need?
Yes
No
Child: Please provide details of your child's diagnosis.
Child: Please provide current list of your child's medications
Child Activities
Child: Please share activities your child enjoys
Child: My child needs encouragement to:
Child: My child does NOT enjoy:
Child: Please do not ask my child to:
Child: My child learns and participates best when the teacher:
Child Physical Needs
Child: Describe your child's vision using the options below:
Not Impaired
Impaired
Wears Contacts/Glasses
Blind
Other
Child: Optional: Share additional information regarding your child's vision.
Child: Describe your child's hearing using the options below:
Not Impaired
Impaired
Uses hearing aids or cochlear implants
Deaf
Other
Child: Optional: Share additional information regarding your child's hearing.
Child: Does your child use any devices for support? (Example: speech app on iPad)
Child: Describe your child's motor skills using the options below:
No impairment
Impaired motor skills
Uses a walker
Uses braces
Uses prosthetics
Uses a wheelchair
Other
Child: Optional: Describe your child's motor skills:
Child: Describe your child's toileting needs using the options below:
Toilets independently
Currently being potty trained.
Potty trained, needs assistance
Wears diapers
Other
Child: Optional: Share additional information regarding your child's toileting needs.
Child: Describe any additional physical needs:
Child: List all allergies (Ex: Food, Medications, etc.)
Child: Instructions in the event there is exposure to allergen:
Child: List additional concerns regarding allergies or your child's eating habits.
Child: Communication
Child: Check all that apply: My child communicates using
Sentences
Phrases
Words
Babbles
Gestures
Sign Language
Speech device
Other
Child: Optional: Describe additional information regarding how your child communicates
Child: My child can understand what others say:
All of the time
Most of the time
Some of the time
Rarely
Child: My child lets someone know what he/she needs by:
Child: Are there any behaviors/phrases that you anticipate we might need help interpreting?
Child: Helpful tips for communicating with my child.
Child: Great topics of conversation with my child:
Child: Behavior
Child: Please check all that apply. The following desccribe my child's behavior:
Outgoing
Shy
Plays in groups well
Has difficulty playing in groups
Adapts to new situations well
Adapts to new situations with difficulty
Responds to correction well
Responds to correction with difficulty
Is sometimes destructive
Sometimes threatens others
Sometimes hits, bites, or hurts others/self
Sometimes attempts to run away
Hyperactive and/or ADD
Other
Child: Optional: Please share additional information regarding your child's behavior.
Child: My child responds to separation from his/her parents by:
Child: My child is best comforted by:
Child: What oppositional behavior might we encounter with your child and how do you handle this behavior at home or at school? Please be specific so that we can provide consistent care.
Child: Describe your child's fears and/or dislikes.
Child: Does your child have an FBA (Functional Behavioral Analysis?
Yes
No
Child: Is there any other information that would be helpful for us to know to best care for your child?
Child Waivers
Child: I understand that pictures and film my be taken at Embrace or NightOWLS events for the purposes of publicity, pictorial recordings, and identification. I give my permission for my child to be photographed while at Signal Pres.
I agree
I disagree
Child: For NightOWLS Families only: I will provide all food and drink items for my child while attending NightOWLS. I understand that the staff cannot provide these items for my child.
I agree
I disagree
Child: I will provide all diapers, clothing, and needed supplies for my child while attending Embrace or NightOWLS events. I understand that the staff cannot provide these items for my child.
I agree
I disagree
Child: I authorize Signal Pres to administer medical assistance in case of an emergency. I understand that in case of a medical emergency, 911 will be called. Upon arrival, EMS will administer emergency assistance and if necessary, my child will be transported to the nearest medical facility for treatment. I understand that I will be contacted by Signal Pres staff via the phone numbers I have provided. I understand that we will be responsible for payment of all EMS, hospital, and physical charges for emergency services for my child.
I agree
I disagree
Child: I have fully disclosed to Signal Pres all pertinent facts about my child’s disability and accept full responsibility for failure to do so.
I agree
I disagree
By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. Check the box to agree.
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