Respite Care Form

Child's Information

Child's Name

Nickname (if any)

Age

Birthdate

Gender

Male

Female

Any Allergies

Physical and Mental Health Conditions

Medication & Instructions

Any Limitations

Behavior Concerns

What Works if He/She Has an Issue

Goals you'd like us to work on

Favorite Foods

Bedtime Routine

Other Information

Car Seat

Car Seat (with back)

Car Booster Seat

No Car Seat Needed

Potty Training

Not Potty Trained

Day and Night

Daytime Only

Diaper Size (if needed)

Goodnites Nighttime Protection Size (if needed)

Weight

Top Size

Pant Size

Shoe Size

Foster Parent Information

Foster Father Name

Foster Father's Mobile Phone

Foster Mother Name

Foster Mother's Mobile Phone

Home Telephone

Foster Parent Email

Foster Parent Address

City

State

Zip

Social Worker Information

Social Worker's Name

Social Worker's Phone

Social Worker's Email

Respite Care Details

Respite Care Start Date

Start Time

Transportation

Picked Up

Dropped Off

Dropped off at 240 E 3000 N, Rexburg ID 83440

Picked Up Address

Pick Up Instructions

Respite Care End Date

End Time

Transportation

Picked Up

Drop Off

Picked up at 240 E 3000 N, Rexburg ID 83440

Drop Off Address

Drop Off Instructions

Scheduled Supervised Visits During Respite Care

Transition Visit/Activity

I want to provide Respite Care with the least amount of trauma for the child as possible. I am more than happy to visit the child in your home and introduce myself, bring the child to my home and show them around prior to respite care, and/or even spend time with the child so they can get to know me before the respite care.

Visit Foster Home and Meet Child

Bring Child to Respite Home for Visit

Activity with Child

Respite Care Must Be Arranged by Social Worker. Information Provided by Foster Parents Prior to Visit

Child's Information

Foster Parent Information

Social Worker Information

Respite Care Details

Respite Care Must Be Arranged by Social Worker.
Information Provided by Foster Parents Prior to Visit