Client Intake Form

I heard about Take a Break from:
To be completed by Guardian/Caregiver
Contact Information
First Name
Last Name
Country
Address Line 1
Address Line 2
City
State
Postal Code
Phone Number
ext Extension
Ethnicity
Race
Financial Bracket (Annual Income - Household)
Does your family qualify for the free or reduced lunch program?
Gender

Child #1

First Name
Last Name
Gender
Respite Subsidy
Ethnicity
Race
Does your child have any of the following special needs?
Does your child have any food allergies or intolerances or are there foods they CANNOT have?
Are there any special discipline guidelines?
Are there any cultural or religious beliefs that you would like to make us aware of?

Child #2

First Name
Last Name
Gender
Respite Subsidy
Ethnicity
Race
Does your child have any of the following special needs?
Does your child have any food allergies or intolerances or are there foods he/she CANNOT have?
Are there any special discipline guidelines?
Are there any cultural or religious beliefs that you would like to make us aware of?

Child #3

First Name
Last Name
Gender
Respite Subsidy
Ethnicity
Race
Does your child have any of the following special needs?
Does your child have any food allergies or intolerances or are there foods he/she CANNOT have?
Are there any special discipline guidelines?
Are there any cultural or religious beliefs that you would like to make us aware of?

Child #4

First Name
Last Name
Gender
Respite Subsidy
Ethnicity
Race
Does your child have any of the following special needs?
Does your child have any food allergies or intolerances or are there foods he/she CANNOT have?
Are there any special discipline guidelines?
Are there any cultural or religious beliefs that you would like to make us aware of?

Child #5

First Name
Last Name
Gender
Respite Subsidy
Ethnicity
Race
Does your child have any of the following special needs?
Does your child have any food allergies or intolerances or are there foods he/she CANNOT have?
Are there any special discipline guidelines?
Are there any cultural or religious beliefs that you would like to make us aware of?
Questions/Comments