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I hereby authorize the following persons to pick up participant. Participant will only be released to a person designated by the parent/guardian after verification of ID
Please complete a Medial Authorization Form
I give consent for Laura Baker Services Association to secure any and all necessary emergency medical care for participant, including transport to the nearest hospital for emergency services.
Please continue to page 2 to list any additional information, including behavior modifications, that will assist us in supporting participant.
Please provide a copy of the behavior plan.
Potential Challenging Behavior (check all that apply)
LBSA’s Saturday Fun is not a state licensed respite service. The program is staffed largely by volunteers and is not equipped to handle aggressive or dangerous behavior. If participant has exhibited aggressive behavior in the last 12 months, please indicate when, where and under what circumstances the aggression occurred. The Family Support Services Coordinator will contact you to discuss the circumstances of the incident. If participant exhibits aggressive or dangerous behavior while at Saturday Fun, a parent or guardian will be contacted to pick up participant immediately.