Participate

Anchored in Hope Respite Event Registration

The Anchored in Hope Respite program is intended to serve those individuals who require skilled caregiving to meet their special needs. Participants in our program may require continuous care which can be taxing on families. For these families, a short-term break by skilled caregivers is a rare gift. If your child does not fit this unique criteria we ask that you do not register.

Which event would you like to register for?

Fall Festival: October 23, 2024

Batter Up Classic: April 2025

Section 1: Parent/Guardian Information

Name

First Name

Last Name

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact #1

Emergency Contact #2

Participant Information

Name

First Name

Last Name

Age

Diagnosis

T-shirt Size

Participant #2 Name (Optional)

First Name

Last Name

Participant #2 Age

Participant #2 Diagnosis

Participant #2 T-shirt Size

Persons authorized for pickup

Please list allergies and/or special diet requirements for each participant *

Does your child use any equipment for mobility? If yes, please state what equipment:

Please provide us with any additional information about your child that will better help us accommodate their needs while in our care

Section 3: Medical information to be used in case of emergency

Child's Physician or Emergency Treatment Facility

Treatment Facility Address

While in the care of Anchored in Hope Respite no medications will be administered unless authorized by medical personnel in the event of an emergency. Please list your child's medications/major medical history that medical personnel would need to be made aware of:

I do hereby give my consent to Anchored in Hope Respite to obtain emergency medical care in the event that I, my spouse, or alternate contact(s) cannot be reached immediately.

Please choose an option

I agree

I do not agree

Typing your name here serves as your signature

Participate

Anchored in Hope Respite Event Registration

Our nonprofit organization includes 4 programs centered around health and wellness. Learn more about Anchored619 in Allegiance.