Special Needs Family Registration Form

Please note this is not registration for camp. That will need to be done in addition to submitting this form and you can register here

Family Information
Please complete one form per child with special needs
Child's Name *
Child's Name
Birthdate *
Birthdate
Child lives with: *
Street Address
City, State, Zip
Home Phone *
Home Phone
Father's Name *
Father's Name
Father's Cell Phone *
Father's Cell Phone
Mother's Name *
Mother's Name
Mother's Cell Phone *
Mother's Cell Phone
Child's Primary Physician *
Child's Primary Physician
Physician Phone
Physician Phone
Include any health concerns/meds we should be aware of
Sibling(s) who will also be attending FridayNite KidzKlub
Sibling(s) who will also be attending FridayNite KidzKlub
Sibling Birthdate
Sibling Birthdate
First Last, Birthdate (mm/dd/yyyy); First Last, Birthdate
Emergency Contact
In case of an emergency, the following people may be called and are authorized to pick up my child. (Driver's License or ID required)
Name *
Name
Cell Phone *
Cell Phone
Name
Name
Cell Phone
Cell Phone
Address
Address
Care Needs
Vision *
Hearing *
Motor *
Uses *
Communicates using: *
Understands 1-2 step directions... *
Toilet Skills
*
Allergies
Eating Habits
Check all that apply *
Drinks from cup: *
Behavior
Check all that apply *
Does your child have a Behavior Support Plan/IEP/504 Plan? *
Please email any additional documents you would like to share that would help us support your child's behavioral needs to specialneeds@baysideonline.com
Permission/Authorization
Please read the following statements carefully and initial in the designated space indicating that you have read, understand, and agree to the provisions.
Please read the following statements carefully and initial in the designated space indicating that you have read, understand, and agree to the provisions. *
I have read the above statements and agree to the terms designated in each.
Publicity Release *
FridayNite KidzKlub is a respite care program designed to lessen the stress of families caring for children with special needs. Because we will try to reach as many families as possible, in the future, we may publicize the program through social/print media, radio or magazines. The use of your name, your child(ren)’s name or picture is strictly voluntary. If you want to participate in our effort to help other families learn about FridayNite KidzKlub in the future, complete this form and return it to us. The picture may be used for press releases, journal articles, or other positive publicity related to respite programs.
I have read the publicity release above and agree the to selection I chose.
Today's Date *
Today's Date