Parents’ Time Off Registration Form

Personal Information Participant's Full Name Age DOB Diagnosis Allergies Dietary Information

Parent/Guardian Information Parent's Full Name Phone Address Email

Emergency Information Emergency Contact Relationship Phone

Medical Information

Please check the following which apply to your child. Hearing ProblemsNon-AmbulatoryHeart IssuesWears Hearing AidsManual WheelchairCan Feed SelfVision ProblemsMotorized WheelchairAssistance FeedingWears Glasses/ContactsTransfer AssistanceProblems SwallowingCommunicates Without WordsWalkerG-Tube FeedingUses GesturesCrutchesAssistance ToiletingUses Sign LanguageCannot Sit AloneIncontinenceCommunication Aids

Medications

List Medications, Vitamins and Inhalants What is it for? Dose? How often? Assistance?

Helpful Information Behavioral Concerns (kinds of behavior and frequency)

Is there a behavior plan in place? YesNo

Tell us about the participant's interest, likes/dislikes, and anything else you would like us to know. Our goal is to help assist you to have a relaxing and/or productive break. What are some ways you use your respite time?

Payment Information Costs & Tuition Assistance

The Youth Services Parents’ Time Off program is $25 per evening/day. This fee will increase to $30 on March 1st. Thanks to our sponsors, tuition assistance is available if needed.
We require financial statements for verification, such as proof of income and/or disability related expenses. Please contact us at YouthServices@abilityconnection.org or or 214-351-2500 ext. 2273 to be considered.

Please check before submitting.

I have provided the correct information. I have read all of the information on this page. I hold Ability Connection harmless of any associated risks.

7880 Bent Branch Drive, Suite 150

Irving, Texas 75063

214-351-2500

info@abilityconnection.org

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Our Mission

Ability Connection is here to enrich the lives of people with disabilities…one person at a time.

Ability Connection, a Texas-registered 501(c)3 charitable nonprofit, offers programs that serve individuals with disabilities and their families. Contributions to Ability Connection are tax-deductible to the extent of the law. Copies of the organization’s tax returns are available upon request. EIN# 75-0875525