Respite Event Application for New Participant

Your name *

Email address *

PARTICIPANT INFORMATION

Participant's full name *

Participant's preferred name *

Participant's date of birth *

Participant's home address *

CAREGIVER OR GUARDIAN'S INFORMATION

Caregiver or Guardian's full name *

Caregiver or Guardian's address *

Caregiver or Guardian's email *

Caregiver's relationship to the participant *

Spouse

Parent

Sibling

Friend

Other

Caregiver or Guardian's phone number *

Caregiver or Guardian's phone type *

Home phone

Cell phone

Work phone

Select the Respite Event dates plan to attend *

October 25, 2025

February 21, 2026

April 18, 2026

June 6, 2026

August 1, 2026

October 24, 2026

Emergency Contact *

In the event of an emergency that you cannot be reached, the following person may be called and is authorized to pick up participant.

Emergency Contact's relationship to the participant *

Emergency Contact's phone number *

How did you hear about our respite program? *

Messiah Lutheran Church

Community resources

Website

Friend

Other

If you chose "other" please elaborate for us!

What is wonderful about the participant? *

MEDICAL HISTORY

Please note that Messiah Respite Project is NOT responsible for administering medication.

Please list all diagnoses or suspected diagnoses (Alzheimer's, Lewy body, diabetes, hypertension, etc): *

Please list all medications that are taken on a regular basis. *

Please list all allergies to medications. *

Health Insurance company and plan ID #

No files currently selected

Add up to 5 files. Maximum file size 10 MB.

Does the participant have a DNR (Do Not Resuscitate)? *

Yes

If you have a medical plan of care for emergencies or DNR (Do Not Resuscitate) order please upload a file here:

No files currently selected

Add up to 5 files. Maximum file size 10 MB.

Participant's Primary Care Provider (their primary doctor) *

Preferred hospital *

DIETARY AND EATING NEEDS

List all dietary restrictions

Please check all that apply *

Eats independently

Eats independently with prompts

Uses special utensils/cup

Requires supervision/physical assistance while eating

Swallowing difficulties

Other

List any special equipment or positioning needed for eating *

Mobility needs include: *

Walks independently

Uses a cane

Uses a walker

Uses a wheelchair

Needs to be reminded to use their assistive device(i.e. cane, walker, etc.) or to rest often?

Other

TOILET AND HYGIENE NEEDS

Toilet and hygiene needs check all that apply: *

Uses toilet independently

Uses toilet independently WITH REMINDERS

Uses toilet with assistance

Needs transfer assistance with toilet

Follows a toileting schedule

Wears briefs/Depends

Needs assistance changing briefs/Depends (Please provide briefs/Depends and change of clothes if this is sometimes necessary)

Has a catheter

Other

Does toileting cause anxiety? *

List signs, gestures, or behaviors that may indicate the participant's need to use the bathroom: *

Please check all that apply *

Predominantly verbal

Predominantly non-verbal

Hard of hearing in both ears

Hard of hearing in right ear

Hard of hearing in left ear

Visual impairments

Does the participant speak any languages besides English? *

Yes

List additional languages the participant speaks

check all that apply *

Speaks clearly-may need extra time processing information

Requires prompts/cues to interact or to do tasks

Word or phrases (that participant speaks) are hard to understand

Participant can express basic needs and wants by: *

Speaking

Eye contact

Gestures

Signs

Assistive technology, such as picture boards, books, talkers

Other

Please list any behavioral concerns/behaviors that we should be aware of (i.e. aggressive, frustration, wandering, etc.)

How have you previously addressed this issue?

Participant's hometown (where he/she spent the most time when growing up): *

Participant's past occupation/job: *

Participant's most proud accomplishment: *

Participant's highest education/schools attended: *

Was he/she ever *

Married

Divorced

Widowed

Single

Is he/she currently married? *

Yes

Is he/she a veteran? *

Yes

Is he/she religious? *

Yes

If he/she is a member of a church or faith community, please list below:

Does he/she have children, grandchildren, nieces, or nephews? *

Yes

Does he/she get along with children? *

Yes

Does he/she like animals? *

Yes

Does he/she have a pet? *

Yes

Does he/she recognize the names of primary loved ones? *

Does he/she recognize self in the present or past? (How old does he/she think they are?) *

Participant's past hobbies/clubs: *

Participant's current hobbies or activities he/she enjoys doing (i.e. music, singing, dancing, games, reading, walking, etc): *

Activities he/she DOESN'T enjoy: *

Activities he/she does well: *

Participant becomes upset or angry when: *

Participant is calmed by: *

Other additional things to know: *

I agree and consent *

Please update this plan yearly or as changes occur. We share this data with the Nebraska Lifespan Respite Network. This information is limited to information about how many families participate and the age/gender of the participant. We will not release any personal information about your loved one or family.

EMERGENCY MEDICAL AND FIRST AID CONSENT

I give permission for Messiah Respite Project to provide all necessary basic emergency or dental care or first aid. *

This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent, unless a DNR signed order is in the chart. The health care provider is required to try to contact me or the other emergency contact listed.

I consent

I do not consent

PHOTOGRAPH RELEASE CONSENT

Photograph release consent *

I give Messiah Respite Project permission to use my name or my participant's name and/or picture in presentations, media releases, newsletters and marketing materials solely for the purpose of promoting Messiah Respite Project.

I consent

I do not consent

WAIVER OF LIABILITY CONSENT

Waiver of liability consent *

I agree to release Messiah Respite Project and all staff and volunteers from all liability for any additional illness or injury, and for any accidental damage or destruction of individual property during the provision of respite care services.

I consent

I do not consent

Thank you for applying! We will be in touch with you soon!

*PLEASE MAKE SURE AND CLICK SUBMIT AT THE BOTTOM OF THE PAGE. YOU WILL RECEIVE A COPY OF YOUR RESPONSES TO THE EMAIL YOU PROVIDED IF YOUR APPLICATION WAS RECEIVED. IF YOU DO NOT RECEIVE A COPY AND FEEL YOU HAVE SUBMITTED AN APPLICATION. PLEASE REACH OUT TO MOLLIEGEORGE@UNOMAHA.EDU TO MAKE SURE IT WAS RECEIVED. THANK YOU!

Respite Event Application for New Participant

PARTICIPANT INFORMATION

CAREGIVER OR GUARDIAN'S INFORMATION

MEDICAL HISTORY

DIETARY AND EATING NEEDS

MOBILITY NEEDS

TOILET AND HYGIENE NEEDS

COMMUNICATION NEEDS

BEHAVIOR MANAGEMENT

SOCIAL HISTORY

EMERGENCY MEDICAL AND FIRST AID CONSENT

PHOTOGRAPH RELEASE CONSENT

WAIVER OF LIABILITY CONSENT

Thank you for applying! We will be in touch with you soon!