PB County: Respite Services Available

[Guest guest]

Respite Services Available

See application below:

Florida DD Council Hurricane Relief Project

Program Application for Participation

Participant’s Name: ______________________________________ DOB: __________

Name of parent/ guardian: _________________________________________________

Home Address: __________________________________________________________

Primary Telephone #: ___________________ Secondary Telephone #: ______________

Emergency contact name and telephone #: _____________________________

Physician’s name and telephone number #: _____________________________

Participant’s Disability: ____________________________________________________

Medical Condition/Needs/Concerns: __________________________________________

________________________________________________________________________

Allergies: _______________________________________________________________

Please circle the program and the funding that your child/adult is eligible for and list the program name and if they currently or previously attend below. This information is to determine eligibility only, no other service authorization of eligibility criteria will be needed.

Program Type

Program Name/ Site

Current

Previous

Funding

Birth to 3 yrs

Part C

School System

Except. Student Ed.

Adult Day

Med-Waiver

Recreation

Dev. Dis. Program

Respite

Dev. Dis. Wait list

Other

My child has / has never participated in one of The Arc’s center or home based program.

Circle service preference: In my home At a local school/ community center

Please list and siblings and their ages that will also need care: ___________________________

_____________________________________________________________________________

Circle following hurricanes that have impacted your family: Charley Frances Jeanne

How did the recent hurricane create the need for respite services?

_____________________________________________________________________________

_____________________________________________________________________________

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How will this service help you to take care of restoring the necessities for your family?

_____________________________________________________________________________

_____________________________________________________________________________

What other services would you need to assist you?

_____________________________________________________________________________

I hereby authorize The Arc of Palm Beach County to release the information contained in this Participant Profile to Resources, Inc. to be used for the purpose of evaluating the Florida Developmental Disabilities Council Inc., Natural Disaster Project.

__________________________________________ ______________________

Parent or legal guardian (signature) Date

The information recorded above is correct to the best of my knowledge.

__________________________________________ ______________________

Parent or legal guardian (signature) Date

Please return completed application to:

The Arc of Palm Beach County

1201 Australian Avenue

Riviera Beach, FL 33404

Fax:

Services will be granted on a first come first serve basis. We will do everything we can to provide as much respite services for your family as the grant will allow.

For questions you please contact Pam Heyer or Rosie Portera at .

Complete this page only if your child has not participated in one of The Arc’s center or home based programs within the last two years.

My child enjoys the following activities: ____________________________________________

______________________________________________________________________________

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How did the recent hurricane create the need for respite services?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

How will this service help you to take care of restoring the necessities for your family?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

What other services would you need to assist you? ________________________________

_____________________________________________________________________________________

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