Activities to be offered / Games Puzzles Cooking Video games Music available within the home TV / Movies Crafts Internet access Computer (check all that apply) Other (list): Items individual will bring for in-home entertainment Activities to be offered / Library Bowling Walk in park / neighborhood Out to eat available within the Shopping Out to movies Worship services community (check all that Other (list): apply) Spending money / gift cards Ledger to be kept Receipts to be kept individual will bring for their Individual able to manage their own money, no ledger or receipts required cost of community events Other (describe): Agency-owned vehicles Staff-owned vehicles Transportation to be Generic public transportation Specialized public transportation provided during respite stay Walking to nearby (check all that apply) Other (describe): None Tube feeding only Liquid / soft / puree diet Mealtime supports, Food cut into bite-sized pieces Diabetic allergies, and/or Needs staff supervision and assistance while eating accommodations Other (describe): Medical devices to be used during based on None Hoyer lift Bed rails Helmet assessed need (instructions Other (describe): for use to be provided to staff) Necessary environmental None Cleaning supplies locked safety accommodations Other (describe): Medications Wheelchair Walker Briefs Toiletries Other items individual will bring with them (check all Communications that apply) medical device / equipment: For communication device will not provide support for use of communication device if applicable, indicate staff Staff will provide support for use of communication device support and instruction for If support is provided, staff instructions include: use of device Overnight planned Respite Service Provider review and signature SIGNATURE OF PERSON COMPLETING FORM DATE PRINTED NAME Part 2. To be completed by parent / guardian / caregiver reviewing Respite Agreement. Medication changes since initial respite application None List: completed Health, behavioral or changes since initial respite None List: application completed Any other identified needs and/or changes required to respite agreement: None Yes (please describe): I understand that there are some known risks with the use of medical devices. After considering the anticipated benefits and safety risks, I consent for the staff to use the following medical devices: None Hoyer lift Bed rails Helmet Other (please describe): Signatures
Activities to be offered / available within the home (check all that apply) Games Puzzles Cooking Video games Music TV / Movies Crafts Internet access Computer Other (list): Items individual will bring for in-home entertainment Activities to be offered / available within the community (check all that apply) Library Bowling Walk in park / neighborhood Out to eat Shopping Out to movies Worship services Other (list): Spending money / gift cards individual will bring for their cost of community events Ledger to be kept Receipts to be kept Individual able to manage their own money, no ledger or receipts required Other (describe): Transportation to be provided during respite stay (check all that apply) Agency-owned vehicles Staff-owned vehicles Generic public transportation Specialized public transportation Walking to nearby Other (describe): Mealtime supports, allergies, and/or accommodations None Tube feeding only Liquid / soft / puree diet Food cut into bite-sized pieces Diabetic Needs staff supervision and assistance while eating Other (describe): Medical devices to be used during based on assessed need (instructions for use to be provided to staff) None Hoyer lift Bed rails Helmet Other (describe): Necessary environmental safety accommodations None Cleaning supplies locked Other (describe): Other items individual will bring with them (check all that apply) Medications Wheelchair Walker Briefs Toiletries Communications medical device / equipment: For communication device if applicable, indicate staff support and instruction for use of device will not provide support for use of communication device Staff will provide support for use of communication device If support is provided, staff instructions include: Overnight planned Respite Service Provider review and signature SIGNATURE OF PERSON COMPLETING FORM DATE PRINTED NAME Part 2. To be completed by parent / guardian / caregiver reviewing Respite Agreement. Medication changes since initial respite application completed None List: Health, behavioral or changes since initial respite application completed None List: Any other identified needs and/or changes required to respite agreement: None Yes (please describe): I understand that there are some known risks with the use of medical devices. After considering the anticipated benefits and safety risks, I consent for the staff to use the following medical devices: None Hoyer lift Bed rails Helmet Other (please describe): Signatures
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