2014-2015 Breathe Respite Sibling Form

**Please complete one form for every sibling attending. Child’s Name:______

Child’s age: ______Child’s Birthday: ______

Parent’s name: ______

In order to help our volunteers get to know your child, please tell us about your child’s likes/dislikes.

If your child has troubling separating from you, do you have any suggestions that would help ease this time?

Does your child want to be separated from their sibling, spend their evening with sibling and buddy or just check in from time to time?

We are serving cheese pizza, pretzels, fruit, water and juice during Breathe. Does your child have any food allergies or eating concerns that we need to be aware of. (Note: Breathe is a peanut free event).

Please include any additional information to help your child have a fun and safe evening.

Please mail forms to the following BREATHE committee member at least three days prior to BREATHE event:

Linda Haskenhoff 8851 King’s Orchard Trail Chagrin Falls, OH 44023 OR [email protected]