Registration

Respite Night Family Registration

If interested in having your child/children attend a Respite Night, please complete and submit this form. Respite Night contact is Danelle Mills, dmills@firstfreelincoln.org, (402) 483-7635. If you have problems with completing this online registration form, please contact Danelle to provide your info directly to her.

Provide Contact Information:

First name*

Last name*

Best phone number to reach you*

Best e-mail address to reach you*

Provide Info For Children Attending:

Child #1 (with special needs):

First name

Last name

Birth date

Child #2 (with special needs):

First name

Last name

Birth date

Child #3 (with special needs):

First name

Last name

Birth date

Child #4 (with special needs):

First name

Last name

Birth date

Child #1 (sibling):

First name

Last name

Birth date

Child #2 (sibling):

First name

Last name

Birth date

Child #3 (sibling):

First name

Last name

Birth date

Child #4 (sibling):

First name

Last name

Birth date

Child #5 (sibling):

First name

Last name

Birth date

Child #6 (sibling):

First name

Last name

Birth date

Complete Plan of Care Form:

A Plan of Care form needs to be completed for each of your children with special needs that will be attending Respite Night. This form is valid for one calendar year. If you are a returning family, your Plan of Care form is valid if it was completed on/before October 20, 2017.

Click here to download an editable pdf file of Plan of Care form. Completed form can then be e-mailed to Danelle Mills at dmills@firstfreelincoln.org or mailed to First Free Church (3280 S. 84th St. Lincoln, NE 68506). This form is also available at firstfreelincoln.org/plan-of-care.

All Plan of Care forms must be received on/before October 16, 2017 for families planning to attend October 20 Respite Night.