Weekends with Malaikah Parent Sign Up

Days and times you would like to receive respite care

Provide what dates work best for you:

Preferred Time:

Parent/Guardian Information

First name

Last name

Relationship to Child

Phone

Emergency Contact Full Name

Emergency Contact Phone

Child Information

Child's First Name

Child's Last Name

Child's Age

Child's Gender

Child's Date of Birth

Month

Day

Year

Disability Information:

Diagnosis/Disability:

Functional Level (e.g., mild, moderate, severe):

Mobility (e.g., independent, uses assistive devices, requires assistance)

Allergies (if any)

Dietary Restrictions (if any):

Communication and Behavior

Preferred communication method (e.g., verbal, sign language, AAC device):

Known triggers (if any)

De-escalation techniques (if any):

Preferred activities and interests:

Medical Information

Doctor's Name

Doctor's Contact Number

List any current medications and dosages:

Additional Information

Please provide any other relevant information that will help us create a positive and supportive environment for your child:

Consent and Liability Release

By submitting this form, I acknowledge that the respite care services provided by The Malaikah Foundation during the event are voluntary and extended as a courtesy

Parent/Guardian Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Today's Date

Month

Day

Year