Village Center Respite Nights – Registration & Consent Form

Village Center Respite Nights – Registration & Consent Form
Section 1: Caregiver Information
Primary Caregiver Name*

First NameLast Name
Relationship to child*

Foster parentAdoptive parentKinship caregiver (family member)Biological parentOther
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Emergency Contact*

First NameLast Name
Emergency contact phone *
Please enter a valid phone number.
List any individuals that are able to pick up the child AND their phone number (we will check IDs)
Section 2: Child Information
Name and ages of all of the children who are attending*
Allergies for any of the children?
Medical conditions or special needs we should be aware of?
Current medications? (We cannot administer medications, but list any emergency medications here)
Section 3: Behavior & Support Needs

Please help us support your child well by sharing any relevant information.
Does your child(ren) have any of the following? (Check all that apply)*

Difficulty with transitionsSensory sensitivitiesHistory of elopementAggressive behaviorsAnxiety or emotional regulation challengesNone of the aboveOther
Please explain in as much detail as we may need. Which child? What works for them? How can we be helpful if we encounter these behaviors?
Section 4: Sick Policy (Required)
To protect the health of all children and staff:

Children must be symptom-free for 24 hours before attending.
Children may not attend if they have a fever, vomiting, diarrhea, contagious illness, or unexplained rash.
ACTION, Inc. reserves the right to deny care if a child appears ill upon arrival.
I understand and agree to the sick policy.*

Yes
Section 5: Incident & Injury Policy (Required)
While ACTION, Inc. takes reasonable precautions to maintain a safe and supportive environment, participation in Respite Nights may involve normal childhood activities that carry inherent risks.

By signing below, I acknowledge and agree that:

ACTION, Inc., its staff, volunteers, and partners will not be held liable for minor or incidental injuries that may occur during participation, except in cases of gross negligence or willful misconduct.
I understand that reasonable supervision will be provided, but accidents and injuries may occur despite precautions.
I voluntarily assume these risks on behalf of my child.
I have read and agree to the liability and injury waiver.*

Yes
Section 6: Supervision & Respite Disclosure (Required)
Respite Nights are designed to provide temporary relief for caregivers in a supportive, supervised environment.

Respite care is not therapy or clinical treatment.
Children are supervised by trained staff following safety ratios.
ACTION, Inc. does not provide one-on-one care unless pre-approved.
I understand the scope and purpose of respite care.*

Yes
Section 7: Behavior & Safety Expectations
For the safety of all children:

Children must be able to participate safely in a group setting.
Severe or unsafe behaviors may result in early pickup.
Caregivers agree to be reachable during respite hours.
I understand and agree to the behavior and safety expectations.*

Yes
Section 8: Authorization for Emergency Medical Care
In the event of an emergency, I authorize ACTION, Inc. staff to seek emergency medical care for my child if I cannot be reached.*

Yes
Section 9: Photo & Media Consent (Optional)
Photos may be used for internal documentation or promotional purposes.*

Yes, I consentNo, I do not consent
Section 10: Acknowledgment & Signature
By signing below, I confirm that all information provided is accurate and that I agree to all policies listed above.

Clear
Date/ Time
$30 for one child; $15 per additional sibling

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USDThis is considered a donation to the Village Center and helps to keep our programs running! Your donation is tax deductible. Please ensure the amount is correct before continuing to ensure your child(ren)'s space at respite night.
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Village Center Respite Nights – Registration & Consent Form

Section 1: Caregiver Information

Section 2: Child Information

Section 3: Behavior & Support Needs

Section 4: Sick Policy (Required)

Section 5: Incident & Injury Policy (Required)

Section 6: Supervision & Respite Disclosure (Required)

Section 7: Behavior & Safety Expectations

Section 8: Authorization for Emergency Medical Care

Section 9: Photo & Media Consent (Optional)

Section 10: Acknowledgment & Signature