Registration

Respite Night Family Registration

If interested in having your child/children attend the February 1, 2019 Respite Night, please complete and submit this form. This online registration form needs to be completed/submitted for each Respite Night that your child(ren) attend.

We also provide childcare for siblings, birth through age 13.

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*

How did you hear about this Respite Night Event?
ChurchFacebookFlyerElectronic SignSchoolTherapistWord of MouthFriend

Provide Info For Children Attending:

We provide a pizza dinner for the children along with Goldfish crackers, lemonade and water. Please indicate with each of your children attending whether or not they will be eating the dinner we provide. You are welcome to send dinner with your child(ren).

Child #1 (with special needs):

First name

Last name

Age

Gender
MaleFemale

Will this child be eating the dinner provided at Respite Night?
YesNo

Child #2 (with special needs):

First name

Last name

Age

Gender
MaleFemale

Will this child be eating the dinner provided at Respite Night?
YesNo

Child #3 (with special needs):

First name

Last name

Age

Gender
MaleFemale

Will this child be eating the dinner provided at Respite Night?
YesNo

Child #4 (with special needs):

First name

Last name

Age

Gender
MaleFemale

Will this child be eating the dinner provided at Respite Night?
YesNo

Child #1 (sibling):

First name

Last name

Age

Gender
MaleFemale

Will this child be eating the dinner provided at Respite Night?
YesNo

Child #2 (sibling):

First name

Last name

Age

Gender
MaleFemale

Will this child be eating the dinner provided at Respite Night?
YesNo

Child #3 (sibling):

First name

Last name

Age

Gender
MaleFemale

Will this child be eating the dinner provided at Respite Night?
YesNo

Child #4 (sibling):

First name

Last name

Age

Gender
MaleFemale

Will this child be eating the dinner provided at Respite Night?
YesNo

Child #5 (sibling):

First name

Last name

Age

Gender
MaleFemale

Will this child be eating the dinner provided at Respite Night?
YesNo

Child #6 (sibling):

First name

Last name

Age

Gender
MaleFemale

Will this child be eating the dinner provided at Respite Night?
YesNo

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/after February 1, 2017.

Click here to download a Word document of Plan of Care form. Completed document needs to be e-mailed to Danelle Mills at dmills@firstfreelincoln.org or mailed to First Free Church (3280 S. 84th St. Lincoln, NE 68506).

All Plan of Care forms must be received on/before February 1, 2017 for families planning to attend February 1, 2019 Respite Night.