Elevate Bridgeport

Saturday Academy Respite Program

Starting Saturday, March 21st

from 9am to 1pm

Child's Full Name

Home Address

Child's ethnicity

School

Grade

Preferred Language

Child's Birthday

Month

Day

Year

Parent or Guardian Full Name

Parent or Guardian Phone

Parent or Guardian Email

Emergency Contact Phone

Emergency Contact Full Name

Does your child have a diagnosis? If so, please specify. If not write N/A.

Does your child receive individual therapy?

Youth/Child Strengths (hobbies, skills, interests and sports) be specific

Does your child have any triggers? If so, please specify.

Any behavioral accommodations needed?

Does your child have any allergies or medical condition we should be aware of? Write N/A if not applicable.

What age group is your child in?

Group 1 - ages 6 to 8

Group 2 - ages 9 to 12

Group 3 - ages 13 to 17

I give permission for my child to participate in Elevate Bridgeport's Saturday Academy Respite Program at the Elevate Offices, 180 Boston Avenue, Bridgeport, CT.

I give permission for my child to participate in any off-site adventure activities during the Saturday Academy Respite Program.

I hereby grant Elevate Bridgeport permission to use the above child's likeness in a photograph, video, or other digital media in any and all it's publications or social media.

This document was completed by:

Parent or Guardian

Child & Family Guidance Center Employee

Signature

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