| The Lucas Project

Respite Participant Application

Thank you for your interest in The Lucas Project’s community respite program. We will work with volunteers to provide respite care once a month to special needs families in Western Michigan at Rose Park Reformed Church in Holland, Michigan. There is a $50 fee to cover our operating costs which can be paid at the end of this form, along with an additional $25 fee if your child needs one-on-one support. This fee is refundable if cancellation is submitted two weeks prior to your scheduled respite date. After this period, the fee will be considered a donation to The Lucas Project. Please fill out your contact information to sign up!

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Phone(Required)

Email(Required)

Is your child between the ages of 5-14?(Required)

Yes

We are currently able to provide respite care to children in this age range. We hope to be able to expand in the future.

Will the child have transportation to and from respite care?(Required)

Yes

Contact Information for Person Transporting Child(Required)

First Last

Phone(Required)

Email(Required)

Will the child have a family member, aide, or some kind of one-on-one assistant with them during the duration of the respite care?(Required)

First Last

Phone(Required)

Email(Required)

What is the best way to help your child if they become upset (check all that apply)?(Required)

Does your child have difficulty with activities of daily living (toileting, changing clothes, washing hands, Etc.) which will require assistance while at The Lucas Project Respite Days?(Required)

We will help accomodate bathroom assistance when we have the appropriate staff in place. However, if staffing is not available on your scheduled day, there are two options. You can send a personal aid, or we can call you to come in and assist your child's needs. If you choose to be on call, you must agree to be available during the duration of the respite day. Do you agree to this?(Required)

Yes

Are there any other conditions we should be aware of? If yes, please describe. If no, type N/A.(Required)

Medical(Required)

Please Enter Any Medical Needs We Should Be Aware Of

Is your child prone to seizures?(Required)

Yes

Is your child prone to physical pain?(Required)

Yes

Does your child have decreased pulmonary function (difficulty with stamina and/or breathing when engaged in physical activity)?(Required)

Yes

Please provide a list of current medications in case there is a medical emergency:(Required)

Requested Attendance Date:(Required)

Waitlist Attendance Date:(Required)

Emergency Contact #1:(Required)

First Last

Phone(Required)

Relationship(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Emergency Contact #2:(Required)

First Last

Phone(Required)

Relationship(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Have you completed and submitted the parent packet?(Required)

Yes

If not, please enter your email address so we can send it to you to fill out and turn in prior to your child participating in respite days.(Required)

Respite Care (Required)

This is the price per child for respite care on one designated day.

Price: $50.00

One on One Aid (Required)

If your child will require a one-on-one aid, there is an additional fee of $25

Price: $25.00

Total

Submit Payment Here: https://thelucasproject.betterworld.org/events/respite-days

Respite Participant Application

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