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Family Application Form

*please print clearly

Date________________

Please check the box for the program for which you are applying:

Mother/Guardians Name:___________________________________ Father/Guardians Name:____________________________________ Home Phone_____________________Cell Phone__________________Work Phone_____________ Address______________________________________City_____________State______Zip________ Email_________________________________________________ Childs Name_________________________________________Age______________DOB___/___/___

Diagnosis___________________________________________________

Briefly describe the special needs of your child and describe some of their learning challenges: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Legacy of Hope Austin/2learn2dream

toll free 866-HOPEATX

www.legacyofhopeaustin.org

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Please describe your childs school history, including details that would be important for our team to know in order to provide the best care for your child: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________

Siblings name:_____________________Age:_____________ Siblings name:_____________________Age:_____________ Siblings name:_____________________Age:_____________ Siblings name:_____________________Age:_____________ Note: The following information is collected strictly for Legacy of Hope Austin for statistical purposes. This
information helps Legacy of Hope Austin address questions grantees and donors may have regarding diversity, socio-economic status, etc. Your information will be kept confidential. Thank you for your willingness and honesty .

1. 2. 3. 4. 5. 6. 7.

Family Ethnicity:____________ One or Two Parent Household:____________ Marital Status: Total number of children in family (including child(ren) with special needs):_____________ Familys Income Level (circle one): Mothers Highest Completed Educational Level: Fathers Highest Completed Educational Level: Do you currently receive services from the Division of Services for People with Disabilities? Do you currently receive aid from your school district for their lunch program or any other support program?

Please explain how you think this program might strengthen your family: ______________________________________________________________________________ Please indicate, between 1 and 10, the average stress level on your family as a whole: ________

Legacy of Hope Austin/2learn2dream

toll free 866-HOPEATX

www.legacyofhopeaustin.org

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Release Form for Media Recording

I, the undersigned, do hereby consent and agree that Legacy of Hope Austin, its employees, or agents have the right to take photographs, videotape, or digital recordings of me and/or my child ________________________ and to use these in any and all media, now or hereafter known, and exclusively for the purpose of furthering the mission of Legacy of Hope Austin and its programs. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I do hereby release to Legacy of Hope Austin, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback. I also understand that Legacy of Hope Austin is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result.

Name: Address: Phone: Witness for the undersigned:

Date:

Signature:

Legacy of Hope Austin/2learn2dream

toll free 866-HOPEATX

www.legacyofhopeaustin.org

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Emergency Medical Plan and Release of Liability

Childs Name___________________________________________________________ Parent/Guardian:________________________________________________________ Home Phone____________________Cell Phone____________________Work Phone________________ Address___________________________________City________________State_______Zip___________

In case of emergency and the Parents/Guardians cannot be contacted, please contact: 1) Name_________________________Relationship______________Phone_____________ 2) Name_________________________Relationship______________Phone_____________

Name of insurance____________________________Policy Number________________________ Name of person insured____________________________________________________________ In case of emergency, contact Doctor_____________________________Phone_______________ Doctors address__________________________________________________________________ If my child requires emergency relocation or evaluation due to serious illness, injury or natural disaster, I prefer s/he be taken to (hospital name)_____________________________City_________

Legacy of Hope Austin is in full charge of my child(ren) during my absence. I give them permission to request or approve emergency medical attention needed by my child(ren). Legacy of Hope Austin will not be held responsible or liable in any way for any accident or illness. I maintain responsibility for all medical expenses for my child(ren). ___________________________ Date ___________________________ Date _______________________________________ Parent/Guardian _______________________________________ Witness

Legacy of Hope Austin/2learn2dream

toll free 866-HOPEATX

www.legacyofhopeaustin.org

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Consent and Conditions of Admission

Welcome to the Legacy of Hope Austin programs! We are a non-profit organization working to provide support for parents/caregivers of children with disabilities and/or learning differences and to provide their children with a nurturing environment. In order to insure that your child is provided with the very highest level of professional care, we ask for your cooperation in the following areas: 1. Our policy currently states that if your child is a no show 2 times within a 3 month period, he/she will be removed from our program. Of course, we understand that families who have children with special needs often have extenuating circumstances that frequently require a change of plans. We ask that, if you cannot attend the program on your scheduled day, that you notify us as soon as possible. You will not be considered a no show if you have given us sufficient notice. To ensure the success and results of our programs for children with learning differences, we have a three month trial period for all new families. Please understand that the scholarships provided for our programs are for families who could not otherwise afford such specialized care for their child. We would ask that any family who could provide such care for their child not use this program as a way to receive free services as that is not in keeping with the vision of the non-profit. I_______________________________(parent/guardian) understand that my child is allowed to participate in the Legacy of Hope Austin program as long as he/she is NOT receiving funding from any agency that could provide me with similar services. If at any time that funding becomes available, I will contact Legacy of Hope and inform them of the change. When this happens, I understand that my child will no longer be able to participate in the Legacy of Hope Austin programs. Please thank our volunteers and staff when you pick up your child(ren). They are the only reason we are able to provide this service. Please make sure they know that they are appreciated.

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These policies will be strictly enforced so that we may help as many families as possible. Consent is hereby given Legacy of Hope Austin, its contractors, medical staff, employees and trained volunteers to provide respite care and other health care services to the respite recipient, and to administer medical intervention as necessary and as determined by the Care Plan. It is understood that there is a risk of substantial and serious harm involved in such a service, and such risk is accepted in the hope of obtaining beneficial results from such services. It is understood that now and in the future, the respite recipient and his/her legally authorized representatives have the right to ask questions and receive answers to such questions about the services being provided.

Legacy of Hope Austin/2learn2dream

toll free 866-HOPEATX

www.legacyofhopeaustin.org

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I understand that Legacy of Hope Austin is not responsible for personal property that is not clearly labeled with the respite recipients name. I understand that Legacy of Hope Austins medical staff and employees are not responsible for damage arising out of mislabeled medication. I understand and agree that I shall hold Legacy of Hope Austin harmless, and indemnify them against any and all causes of action, and shall agree not to hold Legacy of Hope Austin liable for any acts of omissions, of for any injuries or damages sustained, and shall agree to accept any and all risks associated with any activity herein.

_______________________________________________________ Parent/Guardian

___________________________ Date

Legacy of Hope Austin/2learn2dream

toll free 866-HOPEATX

www.legacyofhopeaustin.org

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Parents/Caregivers & Individual Rights Policy

Effective Date: February 1, 2011

Parent/Caregiver Rights 1. Parents/Caregivers have the rights to access the childs records and can expect those records to be kept confidential. Process: To access the records the individual, their guardian or agent(s) authorized by them in writing may make a request to the Director. Employees may access the records on a need to know basis with Director/Coordinator. Records are otherwise confidential. 2. Parents/Caregivers have the right to expect that their childs needs are being met such as bathroom, nutrition, cleanliness and entertainment. 3. Parents/Caregivers have the right to expect timely notification of significant incidents involving their child including serious illness, accident, etc. 4. Parent/Caregivers have the right to expect their child to be cared for in a group environment and bathroom breaks will include two staff members and the child. Individual Rights 1. Individuals are entitled to be treated with respect and dignity. 2. Individuals have a right to be free from physical, verbal, sexual or psychological abuse. 3. They also have a tight to be free from neglect, exploitation and mistreatment. 4. Individuals have the right to a safe and sanitary environment. Process: 2night2dream shall provide a healthy, safe and sanitary environment, which complies with federal, state and local laws and regulations. 5. Individuals may expect the following considerations in addition to the right listed above: a. To be treated with consideration, respect and full recognition of individuality. b. Be provided with opportunity for personal privacy with bodily privacy during treatment and care of personal needs. c. Have sufficient trained staff on duty to respond to injuries, symptoms of illness and emergencies. d. Programmatic and emergency interventions to manage inappropriate behavior shall be the least intrusive, effective method of interventions employed only by trained staff with sufficient safeguards and supervision to ensure that the safety, welfare, civil and humanity of the individuals are adequately protected.

Legacy of Hope Austin/2learn2dream

toll free 866-HOPEATX

www.legacyofhopeaustin.org