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Anchored in Hope Respite Event Registration

The Anchored in Hope Respite program is intended to serve those individuals who require skilled caregiving to meet their special needs. Participants in our program may require continuous care which can be taxing on families and therefore denote a need for a short-term break through a service that can provide skilled caregiving as well. If your child does not fit this unique criteria we ask that you do not register.

Which event would you like to register for? (Choose all that apply) *

April 15, 2023 - Batter Up Classic

* Indicates required field

Email *

Participant Name *

First

Last

Participant Age (birth-18yrs) *

Child's Diagnosis *

Parent/Guardian's Name *

Phone Number *

Home Address *

Which even would you like to attend? *

Emergency Contact #1 *

Emergency Contact #2 *

Persons authorized for pickup *

Please list allergies and/or special diet requirements *

Does your child use any equipment for mobility? If yes, please state what equipment: *

Participant t-shirt size *

Please provide us with any additional information about your child that will better help us accommodate their needs while in our care *

Section 2: medical information to be used in case of emergency

Child's Physician or Emergency Treatment Facility *

Treatment facility address *

While in the care of Anchored in Hope Respite no medications will be administered unless authorized by medical personnel in the event of an emergency. Please list your child's medications/major medical history that medical personnel would need to be made aware of: *

I do hereby give my consent to Anchored in Hope Respite to obtain emergency medical care in the event that I, my spouse, or alternate contact(s) cannot be reached immediately. I do hereby give my consent to Anchored in Hope Respite to transport my child for emergency treatment if I, my spouse, or alternate contact(s) cannot be reached. *

I Agree I Do Not Agree

Name *

First

Last

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registration

Anchored in Hope Respite Event Registration

Section 2: medical information to be used in case of emergency