In response to the COVID-19 pandemic, ErinoakKids has made changes to our operations. Please click here for the latest information.
close
arrow_back close
Donate

Respite 18+ Program Application

Time Limited Program - Limited Enrollment

Thank you for your interest in the 18+ Respite in partnership with the Mississauga-Halton Local Health Integration Network (LHIN).
Please take the time to complete this form completely and with as much detail as possible. We estimate that it will take about 30 minutes to complete the form. We recognize that this is a big time commitment, but the information you share will help our team make Respite Centre a positive experience for your family member.

Once you have completed this form, you may request your desired dates for respite through the respite selection form. Please be sure to select "18+ Respite" at the bottom of the first page.


Important Information

Along with mandatory health screening at ErinoakKids sites for all staff, clients and visitors, clients are required to be fully vaccinated against COVID-19 in order to participate in the Respite 18+ program. Any parent/caregiver or visitor who does not show proof of full vaccination against COVID-19 will be required to have Rapid Antigen Testing on arrival.

(other than parent/guardian - must be aware that they are the alternate contact)
Select all that apply
Consent required before each camp for swimming. All persons are 1:1 with staff in the pool.
We require documentation of your family member’s immunizations; please bring with you on your first visit or fax (prior to first visit) to 905-794-0547. You may also upload this below.
Medication directives will be taken by the nurse and listed on the Medication Administration Form.
Please provide details for any concerns or procedures that are relevant.
Specify amount and delivery method (we require the medical order for the oxygen parameters)
I wish my family member to attend ErinoakKids Respite Centre. I have given ErinoakKids the information that will help staff to assist my family member. I understand every effort will be made to contact parents/guardian in the case of an emergency. I authorize staff to seek medical care if necessary.