Respite Care Application


If scheduling more than one child, please complete a separate application for each child.

Upon application and approval, a member of our team will be in touch to discuss scheduling and other details.


Name of Primary Caregiver *
Name of Primary Caregiver
Address *
Address
Phone *
Phone
Are you an adoptive parent? *
Are you a foster parent? *
Have you completed Unplowed Ground Jumpstart or Pre-Adoptive? *
Have you completed an Unplowed Ground Family Intensive? *
Are you currently implementing Unplowed Ground parenting in your home? *
Are you married or single? *
If Married, Spouse's information
If Married, Spouse's information
Address (if different that Primary Caregiver's)
Address (if different that Primary Caregiver's)
Spouse's Phone
Spouse's Phone
Child's Name *
Child's Name
Birthdate *
Birthdate
Does this child have a history of running away? *
Does this child have a history of hurting animals? *
Is your child familiar with "stations"? *
Is your child biological or adopted? *
Emergency Contact *
Emergency Contact
Phone *
Phone
Type name below as your signature.