If interested in having your child/children attend the January 26, 2018 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.
Respite Night contact is Danelle Mills, firstname.lastname@example.org, (402) 483-7635. If you have problems with completing this online registration form, please contact Danelle to provide your info directly to her.
Best phone number to reach you*
Best e-mail address to reach you*
Child #1 (with special needs):
Birth date (include month, day, year)
Child #2 (with special needs):
Child #3 (with special needs):
Child #4 (with special needs):
Child #1 (sibling):
Child #2 (sibling):
Child #3 (sibling):
Child #4 (sibling):
Child #5 (sibling):
Child #6 (sibling):
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 January 26, 2017.
Click here to download a Word document of Plan of Care form. Completed document needs to be e-mailed to Danelle Mills at email@example.com or mailed to First Free Church (3280 S. 84th St. Lincoln, NE 68506).
All Plan of Care forms must be received on/before January 26, 2018 for families planning to attend January 26, 2018 Respite Night.