Child Care Information Pack
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- Junior Watts
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1 Autism Society of Larimer County Family/Community Support Meeting Child Care Information Pack Pre- Registration Required All children must be registered with Respite Care 1 week prior to meeting time. Once paper work (no cost) is filled out families may use the ASLC Family Support Group Child care free of charge. In order to have adequate staffing, we ask families to please plan ahead and make reservations (and take care of paper work) at least 1 week in advance of meeting date. For more information about sign-up procedures please call or Leann@respitecareinc.org
2 Dear Parent, Welcome to Respite Care. We are excited to be working with the Autism Society Support Group. Our desire is to make things easier for you by providing childcare during your monthly meetings. In order to be successful we would like to explain some of our requirements. We will provide care for children under the age of 12 or children with a developmental disability between the age of 1 and 20 years. Children must be scheduled at least one week prior to the meeting. You can schedule your child by contacting us at or leann@respitecareinc.org. Unfortunately, we are unable to care for children with aggressive behaviors. Paperwork must be completed and returned to Respite Care at least 24 hours before providing childcare Due to dietary restrictions, no snack will be provided by Respite Care. If you would like to provide your own snack, we will be happy to feed your child in the dining room. Staff is scheduled from 6:30pm until 8:30pm. Childcare is not provided before or after these times. Parents must be on premise (Respite Care) during the time their child is receiving care If you have any questions, please do not hesitate to contact me. Sincerely, LeAnn Massey Assistant Director
3 Respite Care Inc CHILD CARE INFORMATION By providing the following information, you will be able to assist the Care Provider in giving quality care to your child(ren). CHILD S NAME: CHILD S AGE: CHILD'S DIAGNOSIS (if applicable): EMERGENCY NUMBERS & CONTACTS: Parents must remain on premise during the Autism Support Group Meetings MEDICATIONS: Medications can not be given while children are attending Respitality or the Autism Support Group Meetings ALLERGIES (ie: food, animals, medications, environmental, etc.): TYPICAL BEHAVIOR (ie: rewards for good behavior, methods of discipline for misbehavior, describe behavior challenges, etc.): COMMUNICATION (describe use of sign language, assistive devices, common gestures, body language, etc.): TOILETING (describe toileting schedule, use of adaptive equipment, specific techniques, etc.): PHYSICAL MOBILITY (describe use of adaptive equipment - wheelchairs, AFO's, walkers, glasses, hearing aids, head protective devices, etc.): SEIZURES (if applicable - describe type, frequency, average length, any known auras, any known causes, any known complications, and emergency procedures): FAVORITE ACTIVITIES (ie: recreational, fine/gross motor, favorite music, TV programs, books, places to go, friends to be with, etc.): OTHER:
4 EMERGENCY INFORMATION FORM Child s Name Birth date Diagnosis Mother s Name Home Phone Cell Phone Father s Name RELATIVE OR FRIEND IN CASE OF EMERGENCY (in Fort Collins or surrounding area): Name Name Doctor s Name Dentist s Name Signature: Date:
5 PARENT(S) AUTHORIZATION FOR CARE OF CHILD BY RESPITE CARE, INC. I (we),, the undersigned parent(s)/ guardian(s) of Name of Parent(s)/ Guardian(s) give full power to perform the duties involved in the Name of Child responsible care of our child to Respite Care, Inc. Parent(s)/ Guardian(s) Signature(s) Date STATEMENT OF NON-LIABILITY I (we),, the undersigned parent(s)/ guardian(s) of Name of Parent(s)/ Guardian(s) agree not to hold Respite Care, Inc. liable for any illness Name of Child or accidental injury to my (our) child while he/she is in the Respite Care Program. Date Parent(s)/ Guardian(s) Signature(s)
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