Please enable JavaScript in your browser to complete this form.Family's Last Name: *Father's Full Name: *Mother's Full Name: *Street: *City: *Zip Code: *Primary Email: *Phone Number(s): *Emergency Contact: *Emergency Contact Phone Number: *1. Child's Name: *FirstLastSex: *MaleFemaleDate of Birth: *Special Needs: *YesNo2. Child's Name:FirstLastSex:MaleFemaleDate of Birth:Special Needs:YesNo3. Child's Name:FirstLastSex:MaleFemaleDate of Birth:Special Needs:YesNo4. Child's Name:FirstLastSex:MaleFemaleDate of Birth:Special Needs:YesNo5. Child's NameFirstLastSex:MaleFemaleDate of Birth:Special Needs:YesNoWhat is the primary diagnosis(es) of the child/children with special needs? *Is/are the child/children taking any medicines? (please list dosage and reason for medication): *Is there a history of seizures? *YesNoDoes the individual have any allergies (food, seasonal, animal, etc.)?Is there any other information you would like us to know?Aside from parents, please list other person(s) authorized to pick up your child/children. Authorized person(s) must be at least 18 years old.By providing my name below I verify the accuracy of the information above to the best of my knowledge and I give Parent's Night Out permission to use pictures of the individual in its publications, newsletters, and on its website. *Date: *Once this application is received the family coordinator will be calling to review more specific needs of your child/children.NameSubmit Please enable JavaScript in your browser to complete this form.Child's Name: *FirstLastDate of Birth: *Allergies:Medication: *Prescriber's AuthorizationDosage: *Circumstances for Use: *Special Instructions:Prescriber's Name: *Date of Prescription: *Name of Contact during Respite: *Contact Number during Program: *Relationship to child: *Name of Contact #2 during Respite: *Contact #2 Relationship to child: *Contact Number #2: *Parent Initials: *I authorize a trained volunteer of Under His Wings Respite to administer the medication.Parent Initials: *I understand the person will be transported to the nearest hospital if an EpiPen is administered.By placing your name below you authorize a trained volunteer of Under His Wings Ministry to administer the prescribed medication and understand the individual will be transported to the nearest hospital if an EpiPen is administered. *Date: *CommentSubmit Download Forms Please fill out the application forms and the consent form and please return them to: Under His Wings Respite 4290 Hartland Center Road Collins, Ohio 44726 Family-Packet-2020 Medication_Information Consent-Release-2020
