Jacob’s Ladder Pediatric Rehab Center: Respite Program Intake Packet – Page 1 of 5
Respite Program:
Child’s Name #1 ________________________ Age _______ Birth Date ________________________
Grade: ________ School: ____________________________
Sex:
M ✔
F
Diagnosis/Disability: ___________________________________________________________________
Child’s Name #2 ________________________ Age _______ Birth Date ________________________
Grade: ________ School: ____________________________
Sex:
M ✔
F
Diagnosis/Disability: ___________________________________________________________________
Emergency Contact #1: ___________________________ Relationship to Child: ____________________
Home Address: _____________________________ City: __________________ State :____ Zip: _______
Home Phone: ________________ Cell Phone: ____________________ Email: ______________________
Employer: _____________________ Address: _______________________ Phone: __________________
Emergency Contact #2: ___________________________ Relationship to Child: ____________________
Home Address: _____________________________ City: __________________ State :____ Zip: _______
Home Phone: ________________ Cell Phone: ____________________ Email: ______________________
Employer: _____________________ Address: _______________________ Phone: __________________
Child’s Physician: _____________________________ Phone Number: ___________________________
Waiver of participation and release of liability:
As a condition of participation in the program, I waive any and all claims against Jacob’s Ladder Pediatric Rehab
Center, its affiliates and/or agents for injury or damage that may be sustained as a direct or indirect result of my
child’s participation in program activities. _________ Initial
I give my consent to his/her being administered any emergency medical treatment by a physician or hospital in case of
an accident or illness. ___________ Initial
By signing below, I am acknowledging that I have read and understand the policies, general information, and Liability
Waiver outlined above.
Parent/Guardian Signature __________________________________
Date: ____________________
Jacob’s Ladder Pediatric Rehab Center – Updated August 2015
Jacob’s Ladder Pediatric Rehab Center: Respite Program Intake Packet – Page 2 of 5
The following information is necessary for our records and the funding our organization receives. Jacob’s
Ladder depends upon outside funding to develop and sustain programs offered to its participants.
Therefore your cooperation in providing this information is greatly appreciated. The answers you provide
are confidential.
Ethnicity/Race (check only one):
✔☐African American
☐Asian
☐Caucasian/White
☐Hispanic/Latino
☐Native American
☐Other: ____________
☐Spanish
☐Other: ____________
Primary Language (check only one):
☐English
Family Income Level (Check only one)
☐Under $10,000
☐$10,000 – $19,999
☐$20,000 - $29,999
☐$30,000 - $39,999
☐$40,000 - $49,999
☐$50,000 - $59,999
☐$60,000 - $69,999
☐$70,000 - $79,999
☐$80,000 - $89,999
☐$90,000 - $99,999
☐$100,000 or higher
Does anyone in your household receive one or more of the following (check all that apply):
☐Free or reduced price lunch at school
☐Supplemental Security Income (SSI)
☐Food stamps
☐Medicaid
How did you hear about the Jacob’s Ladder Respite Program?
I understand that in order for my child to participate in the respite program that:
1. I will bring my child to each of the six (6) Saturdays over the six month period.
2. I agree to pay $20.00 for each of the six (6) Saturdays.
3. I will participate in a minimum of 4 parent education sessions over the six month period.
Parent/Guardian Signature: ____________________________
Date: ___________
Jacob’s Ladder Pediatric Rehab Center – Updated August 2015
Jacob’s Ladder Pediatric Rehab Center: Respite Program Intake Packet – Page 3 of 5
Please Complete One for Each Participating Child
Child’s Name: ____________________________________________________________
1. List any food allergies:
________________________________________________________________________
2. List any medication allergies:
_________________________________________________________________________
3. List any other allergies:
_________________________________________________________________________
4. List any medical conditions our staff should be aware of:
_________________________________________________________________________
5. Does your child have Epilepsy/Seizures:
☐Yes
☐No
6. Does your child carry or need an epi-pen for an allergy?: ☐ Yes ☐No
If yes, I give my permission for Jacob’s Ladder staff to administer Epi-Pen _________ Initial
7. List any medications your child is currently taking:
_________________________________________________________________________
8. Use the following key for grading level of supervision required for each task listed:
I = Independent
S = Some Supervision C = Constant SupervisionP = Physical Assist
____ Diaper
____Toileting
____Feeding
____Medication
9. Briefly describe any behavioral issues or special care for your child our staff should be aware of:
____________________________________________________________________________
10. List foods that should be avoided: ________________________________________________
11. List food preferences: _________________________________________________________
I consent to Jacob’s Ladder Pediatric Rehab Center to provide Respite Care services to my child, which may include gross & fine
motor activities, sensory program activities, group social activities, meal prep activities, quiet times and participation in snack and
lunch time activities:
Parent/Guardian Signature: ______________________________
Date: ______________
Jacob’s Ladder Pediatric Rehab Center – Updated August 2015
Jacob’s Ladder Pediatric Rehab Center: Respite Program Intake Packet – Page 4 of 5
PERMISSION TO RIDE IN PRIVATE VEHICLE
I hereby give permission for my son/daughter, __________________________________
(Child’s Name)
To ride with an employee of Jacob’s Ladder to the Center on the following Respite Program Dates:
9/19, 10/17, 11/21, 12/19/2015, 1/16, and 2/20/2016
I waive any and all claims against Jacob’s Ladder Pediatric Rehab Center, its affiliates, the driver, and/or
agents for injury or damage that may be sustained as a direct or indirect result of my child’s participation
in this activity.
In the event of illness or injury to my child while on this travel/activity, I hereby give my consent for
medical or dental care deemed necessary by the attending health care provider or dentist. My child may
be examined and any necessary procedures (medical, dental or surgical), anesthesia, or diagnostic
procedures (lab or x-ray) may be performed under the supervision of a member of the hospital or medical
office staff furnishing such services.
I further acknowledge that I am financially responsible for any medical, dental, ambulance or other health
care expenses which might occur as a result of such illness or injury.
___________________________________________
Signature of Parent/Guardian
___________________
Date
___________________________________________
Print Name
Jacob’s Ladder Pediatric Rehab Center – Updated August 2015
Jacob’s Ladder Pediatric Rehab Center: Respite Program Intake Packet – Page 5 of 5
Photograph/Media Authorization
________ I authorize Jacob’s Ladder Pediatric Rehab Center to photograph my
child(ren).
I give permission for my child to be included in picture/video recording that may be
used on our brochures, newsletters, Donor “Thank You”s, and Jacob’s Ladder’s
Website.
________ I DO NOT authorize Jacob’s Ladder Pediatric Rehab center to photograph
my child(ren).
_______________________________________________
Child’s Name
____________________________________________
Parent/ Guardian Signature
__________________
Date
Jacob’s Ladder Pediatric Rehab Center – Updated August 2015