Respite Night Registration Lebanon Church’s Through The Roof Special Needs Ministry will be starting Respite Night. Please fill out the form below and submit it to Register. If you have any questions please contact Becky Blow at email@example.com or call 843-618-1324. Child's Name (required) Birthdate (required) Parents Names (required) Address Cell Phone Number (required) Your Email (required) Siblings Names Who Will Be Attending (required) Emergency Contacts (required) Doctor's Name Specific Type Of Disability (required) Degree Of Severity Current Medications And Allergies (required) Seizures? (required) YesNo List Any Physical Limitations Please describe your child’s communication abilities Please describe any dietary or feeding needs your child has. Please describe any behaviors that we should be aware of. If behaviors are present what are their triggers? Does your child need help using the restroom? YesNo What activities does your child enjoy the most? Please list any additional info we should be aware of.