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Oakhurst Evangelical Free Church

Respite Event Registration Form

We are so EXCITED to be able to provide this event to the families of our community with disabled children up to the age of 21. This is a FREE event providing loving and compassionate care for children effected by disability (ages 0-21) and their siblings (ages 0-13), so Parents or Full Time Care Givers can enjoy a break for a few hours.

The event will be November 17th from 1:30 pm to 4:30 pm at

Oakhurst Evangelical Free Church

50443 School Road

Oakhurst,Ca.

If you would like to volunteer to help with this event we need help with programs (crafts, snacks, games, etc.) as well as one-on-one care givers. please contact the Church Office at (559) 683-2254 or email to respite@oakhurstevfree.org.

If you would like to have your child(ren) participate in this event please complete the Registration Form below.

WE HOPE TO SEE YOUR THERE!

Respite Event

Registration
DATE: Sat, Nov. 3rd TIME: 1:30-4:30 (volunteers will arrive at 12:30) AGES: 0-21 for those with a disability and 0-13 for siblings who want to attend with them
Date*
Parent/Guardian Name*
Relationship to Child(ren)*
Email*
Day Phone*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Number of Children being Registered*
Please enter a value between 1 and 5.
Child(ren) Information
Name*
Nickname
Disabled or Sibling*
- Disabled
- Sibling
Brief Description of Disability
How does their disability effect them?
Mobility or Adaptive equipment used?
Special toileting instructions?
Allergies or food restrictions?
Additional Comments?
Age*
Please enter a value between 0 and 21.
Birthdate*
Gender*
- Male
- Female
Name
Nickname
Disabled or Sibling
- Disabled
- Sibling
Brief Description of Disability
How does their disability effect them?
Mobility or Adaptive equipment used?
Special toileting instructions?
Allergies or food restrictions?
Additional Comments?
Age
Please enter a value between 0 and 21.
Birthdate
Gender
- Male
- Female
Name
Nickname
Disabled or Sibling
- Disabled
- Sibling
Brief Description of Disability
How does their disability effect them?
Mobility or Adaptive equipment used?
Special toileting instructions?
Allergies or food restrictions?
Additional Comments?
Age
Please enter a value between 0 and 21.
Birthdate
Gender
- Male
- Female
Name
Nickname
Disabled or Sibling
- Disabled
- Sibling
Brief Description of Disability
How does their disability effect them?
Mobility or Adaptive equipment used?
Special toileting instructions?
Allergies or food restrictions?
Additional Comments?
Age
Please enter a value between 0 and 21.
Birthdate
Gender
- Male
- Female
Name
Nickname
Disabled or Sibling
- Disabled
- Sibling
Brief Description of Disability
How does their disability effect them?
Mobility or Adaptive equipment used?
Special toileting instructions?
Allergies or food restrictions?
Additional Comments?
Age
Please enter a value between 0 and 21.
Birthdate
Gender
- Male
- Female
Emergency Contact
In case of an emergency and the parent or guardian cannot be reached, who would be contacted?
Primary Contact Name*
Relationship to Child*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Secondary Contact Name
Relationship to Child
Address
Street Address Address Line 2 City State ZIP Code
Phone
Medical Information
Childs Physician
Physicians Phone Number
Medical Insurance Carrier
Policy #
Acceptance and Comments
Legal Stuff
LIABILITY RELEASE: This event is sponsored by Oakhurst Evangelical Free Church (referred to as "the Church" in these releases). I hereby release "the Church" and the and/or the Leaders/Volunteers from liability in case of injury or illness to the above named Child(ren). If I cannot be reached in the event of an emergency, I give permission for necessary medical care, to secure proper treatment and to order injections, anesthesia or surgery for the above named child(ren). I understand that all charges for service not billed to my insurance carrier will be billed to me as parent/guardian.
Medical Authorization
MEDICAL AUTHORIZATION: By checking acceptance below and SIGNING REGISTRATION the day of the Respite event. I hereby give permission to "the Church" staff/volunteers to secure any medical treatment that may become necessary, except as noted as noted for that child.
Photo Release
PHOTO RELEASE: I hereby grant to "the Church" and to its employees, agents and assigns the right to photograph me or my dependent and to use the photo and or other digital reproduction of him/her to other reproduction of his/her physical likeness for publication processes, whether electronic, print, digital, or electronic publishing via the internet.
*
- I understand and agree to the above Respite event terms.
Parent/Guardian Signature (Sign on day of Respite Event)

Δ

Equipping the Saints,
Edifying the Body,
Evangelizing the World.

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Contact Info

Phone: (559) 683-2254
Fax: (559) 692-2102

50443 School Road
Oakhurst, CA 93644

Sunday Service Times
Sunday School
8:45 am to 9:45 pm
Morning Service
10:00 am to 11:30 am

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