Connected Team Member Arranging Respite
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First Name
Last Name
Connected Resource Family for Respite
*
Your Name (DCFS Worker)
*
First Name
Last Name
Your Email
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Your Phone
*
(###)
###
####
DCFS Supervisor
*
First Name
Last Name
DCFS Supervisor Email
*
DCFS Supervisor Phone
*
(###)
###
####
Respite Request Start Date
*
MM
DD
YYYY
Respite Request End Date
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(no more than 14 days)
MM
DD
YYYY
Sibling 1
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First Name
Last Name
Sibling 1 - Gender
*
Male
Female
Sibling 1 - Date of Birth
*
MM
DD
YYYY
Sibling 1 - Age
*
Sibling 1 - DCFS Client ID Number
*
Sibling 1 - SSN
Sibling 1 - Medicaid # or PASSE Provider and Member ID
*
Sibling 1 - Please list any allergies, current medications, and medical conditions.
*
Sibling 1 - Please list the school, grade, and teacher (if applicable). What is the transportation plan to and from school?
*
Sibling 1 - Describe any behavioral issues.
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Sibling 2
(If there is only one child in this request, scroll to the bottom of the form to sign your name and submit. Otherwise, please continue to fill out the information for all siblings.)
First Name
Last Name
Sibling 2 - Gender
Male
Female
Sibling 2 - Date of Birth
MM
DD
YYYY
Sibling 2 - Age
Sibling 2 - DCFS Client ID Number
Sibling 2 - SSN
Sibling 2 - Medicaid # or PASSE Provider and Member ID
Sibling 2 - Please list any allergies, current medications, and medical conditions.
Sibling 2 - Please list the school, grade, and teacher (if applicable). What is the transportation plan to and from school?
Sibling 2 - Describe any behavioral issues.
Sibling 3
(If there are only 2 siblings in this request, scroll to the bottom of the form to sign your name and submit. Otherwise, please continue to fill out the information for all siblings.)
First Name
Last Name
Sibling 3 - Gender
Male
Female
Sibling 3 - Date of Birth
MM
DD
YYYY
Sibling 3 - Age
Sibling 3 - DCFS Client ID Number
Sibling 3 - SSN
Sibling 3 - Medicaid # or PASSE Provider and Member ID
Sibling 3 - Please list any allergies, current medications, and medical conditions.
Sibling 3 - Please list the school, grade, and teacher (if applicable). What is the transportation plan to and from school?
Sibling 3 - Describe any behavioral issues.
Sibling 4
(If there are only 3 siblings in this request, scroll to the bottom of the form to sign your name and submit. Otherwise, please continue to fill out the information for all siblings.)
First Name
Last Name
Sibling 4 - Gender
Male
Female
Sibling 4 - Date of Birth
MM
DD
YYYY
Sibling 4 - Age
Sibling 4 - DCFS Client ID Number
Sibling 4 - SSN
Sibling 4 - Medicaid # or PASSE Provider and Member ID
Sibling 4 - Please list any allergies, current medications, and medical conditions.
Sibling 4 - Please list the school, grade, and teacher (if applicable). What is the transportation plan to and from school?
Sibling 4 - Describe any behavioral issues.
Please sign giving consent.
*
As the above-named qualified worker/representative of Arkansas Division of Children and Family Services (DCFS), I do hereby place the abovenamed child/children with Arkansas Baptist Children & Family Ministries (Connected Foster Care) for the purpose of respite, not to exceed more than 14 days. DCFS gives consent to Connected Foster Care duly appointed representative(s) to assist the above-named child/children to receive any emergency/hospital treatment, medical treatment, psychological treatment, dental treatment, vision treatment, and/or hearing treatment as may be deemed necessary and expedient by a licensed physician or specialist. DCFS gives consent for the above-named child/children to travel within the state of Arkansas with Connected Foster Care duly appointed representative(s) and/or the respite Connected Foster Care resource families during the respite stay. DCFS gives consent and authorization for Connected Foster Care duly appointed representative(s) to enroll above-named child/children in school and serve in the capacity of guardian concerning academic or educational situations with the school if applicable. DCFS gives consent that while the above-named child/children is in the care of Connected Foster Care, the child will potentially attend church services and other functions of the respite Connected Foster Care resource families during the respite.
First Name
Last Name
