Please enable JavaScript in your browser to complete this form.DateChild's Name *FirstLastChild's NicknameDate of Birth *GenderWho is your health insurance provider *Oregon Health PlanPacificsourceTrillium Health PartnersI don't have health insuranceOther (Please name insurer below)If insurer provider selected is "other" please list insurerWhat is your insurance ID NumberAllergies *Health Concerns *What is the child's preferred languageWhat are your child's interestsPersonal Care Needs: Is your child independent with feedingYesNoIf no, what type of assistance is needed?Behavioral Needs: Does your child typically have meltdownsYesNoDo you know what triggers themYesNoPlease describe triggersHow long do they tend to lastWhat do you do to stop the behavior?Does your child typically show physical aggression towards others?YesNo what Behavioral Personal If yes, please describe triggersBoredom, Frustration, Communication, Other TriggerDoes your child typically show physical aggression toward themself?YesNoIf yes, please describe triggersWhat do you do to stop the behavior?Are there ongoing conflicts with siblings that we should know about?YesNoIf yes, please describe triggersWhat do you do to stop the behavior?What strategies help your child to avoid negative behavior(s)?At what point do you think we should notify you and/or ask for your assistance?Parent/Guardian Information and Emergency ContactParent/Guardian Name *FirstLastParent/Guardian Email *Parent/Guardian Phone *Home Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact and Pick-Up Authorization (Required)The following people are to contact in case of emergency, only if parent/guardian cannot be reached AND are authorized to pick-up the child. (The emergency contact's name MUST match the name on their photo ID.)Name *FirstLastRelationship to childPhoneName *FirstLastRelationship to childPhoneParent/Guardian Authorization *I agree and give my permissionI acknowledge that this information on the OFSN Tell Us About Your Child and the OFSN Parent/Guardian Information and Emergency Contact is true and accurate. I authorize that my and my child(ren's) information can be shared with the Family Support Specialist and other OFSN staff and volunteers involved in the care of my child during Parent's Night Out Respite. I understand that Parent's Night out Respite is from _____________________PM to ____________________PM, and that I, as the parent will pick-up my child at _______________________PM. If an emergency arises, my emergency contact on this form will be contacted in the order listed to pick-up my child and will show proof of ID at the time of pick-upParent/Guardian SignatureDateSubmit 2025-01-30
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