Brett Staples
Basically it is just an incredible gift to get away with each other and away from the daily responsibilities of caring for Brett. Our two older children are not at home...one moved out of state and the other is away at college.

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Family Information

Child's Name


Mother's Name


Father's Name


Address


City


State


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


Medications


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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