Matthew and his twin sister Marie have Cerebral Palsy. Both Marie and Matthew are confined to wheel chairs and need daily care. If you can imagine taking care of one handicapped child, how about two? Their parents use the respite care from Children Are Precious to go on a much needed vacation with their other daughter.

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Family Information

Child's Name

Mother's Name

Father's Name




Postal Code

Home Phone

Work Phone

Emergency Phone

Does child live with both parents?

If no, indicate other parent address:
Parent 2 Address

Parent 2 City

Parent 2 State

Parent 2 Postal Code

Insurance and Income

What insurance is your child covered by?

Do you receive social security income (SSI)? If yes, list amount

Total household income

Mother's occupation

Father's occupation

Number of children

Please list family obligations or hardships

Child's Medical History

Date of birth (mm/dd/yyyy)

Child's primary care physician

Primary care physician's address and phone number:
Physician's Address

Physician's City

Physician's State

Physician's Postal Code

Physician's Phone

Is your primary care physician a Beaumont Hospital physician?

Medical condition


Does your child have home nursing care?

Briefly describe type of assistance and treatments provided by home nursing care

If yes, average hourse per week

If yes, what agency is used?

Hours covered by insurance

Describe the nursing care provided by the family

Please indicate how your family would benefit from respite care provided by Children Are Precious.

Please list any support groups your family participates

Release Information

Would you be willing to share your family's experience with Children Are Precious with other families in need?

Would you be willing to share your family's experience with Children Are Precious for out website, family support groups, and fundraising activities?

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