2014-2015
Breathe Respite Buddy Form
Please include a copy of your child’s behavior plan, along with this form, so we can best support your child.This form will be shared with our Breathe volunteers to help them plan a fun and safe night for your child.
Child Name: ______
Child’s age: ______Child’s Birthday: ______
Parent’s name:______
Parent’s contact phone number for the evening: ______
In order to help our volunteers get to know your child, please tell us about your child’s likes (What do they like to do or talk about? ie: dolls, LEGOS, games, puzzles, sports. Favorite activities?)
Please tell us about your child’s dislikes.
We realize that sometimes children can become overstimulated or require redirection. What are some specific triggers that may upset your child? (Animals? We have therapy dogs attend BREATHE? Loud noises? Bright lights?)
What is your best tip in this situation? How do you handle this at home/school?
What do you recommend we do to help them feel better?
Are there any behaviors/symptoms your child’s buddy should be aware of? (i.e. aggressive tendencies, child may seem distant before seizures, agitated if hungry?)
Does your child have a behavior plan that we should be aware of? Please include a copy of your child’s behavior plan so we can best support your child
Is your child verbal? Do they us a communication device or chart? If so, please bring that with your child to BREATHE. If not, do you have any suggestions for us on how we can best communicate with your child?
During the Breathe event, we will have the following activities available, please check any areas that you feel your child would enjoy or note any areas of dislike:
crafts Wii, movies
games and puzzles indoor basketball
yoga quiet story area
music room entertainment (changes for each event)
gross motor area therapy dogs
Does your child have any food allergies or special diet that we need to be aware of? If so, please explain. (Please note: Breathe is a peanut-free event).
We are serving cheese pizza, pretzels, fruit, water and juice during Breathe. Please choose one. Please check one box
It is fine for my child to be offered food during the Breathe event.
I will be providing my child with food and/or drinks from home and prefer for them to only eat what I provide.
Does your child need any assistance with eating or are there any eating concerns we should be aware of? (i.e. cutting food into small pieces, can they self feed, do they need a quiet environment to eat in, do they choke easily? etc.).
Does your child require assistance with the bathroom? If so, please let us know how we can help. (i.e. diapering, frequent reminders, help with clothes, etc.) Toileting needs will be assisted by our medical team.
If your child has troubling separating from you, do you have any suggestions that would help ease this time?
Do they need to be paired up with a sibling or have some time apart?
Please include any additional information to help your child have a wonderful experience.
Please mail these forms to the following BREATHE committee member, Linda Haskenhoff, at least five days prior to this upcoming BREATHE event. She will be sure to keep all information confidential and secure:
Linda Haskenhoff
8851 King’s Orchard Trail
Chagrin Falls, OH 44023
OR