Course fee is $250 per person.
A non-refundable registration fee of $25 per person must be received by Dream House five (5) days prior to first class. The course fee balance of $225 must be paid in full before the Day 1 Class session begins.

I understand that classes begin promptly and by arriving more than 20 minutes past class time may result in a missed class.

I understand that the information, provided by the Dream House for Medically Fragile Children, Inc. Family for Keeps® Program – Education and Skills Training, is basic.

The physician who oversees the care of the child(ren) is the authority. The physician’s advice and directions will be followed when providing care for any child.

REGISTRATION FORM
Course Date:	Enter course dates you are requesting
Name:
Occupation:
Email:
Home Address:
City:
State:
Zip:
County:
Preferred Telephone:
Highest Level of Education:
How did you learn about this training?
Reason(s) for taking this course:
I am a biological parent or relative of a medically fragile/special needs child.
I am a foster or adoptive parent of a medically fragile/special needs child.
I plan to be a foster or adoptive parent of a medically fragile/special needs child within the next six months.
I am a respite care provider who is now or would like to provide respite for a medically fragile child.
I am a community or extended family member interested in assisting a family with a medically fragile child.
I am a foster parent with no experience or plans to care for a medically fragile child, but want to learn more.
Other - please explain:
How many children are in your care?
How many are foster children?
How many are medically fragile?
If you are not already caring for a medically fragile child, are you considering doing so?
If you are a foster parent, with which agency are you affiliated?
What are your current sources of support (emotional and/or spiritual)?
Have you requested support or assistance from your community?
Have you received assistance or support from your community?
If yes, please provide the name of the organization and the type of support you have received.
Would you like to learn about additional resources that provide support and assistance to families with medically fragile children?
What needs do you or your child have that would make it easier to provide care?
Please list the AGE, RACE and MEDICAL PROBLEM of your medically fragile child(ren).
Please list three (3) things that are most STRESSFUL in your life.
What are your most effective COPING SKILLS for dealing with stress (talking with others, time alone, exercise, etc.)?
If a full day is 100%, think about your child's day. What percentage of your time is spent on the following needs?
Physical or Medical %
Spiritual %
Emotional %
Social
Please rank your current SKILLS KNOWLEDGE. '0' is no knowledge, '1' is some knowledge, '2' is wish to learn more or get more practice, '3' is have good knowledge or experience
Suctioning and Trach care
Feeding Tubes (G, J, NG, GJ)
Proper Body Mechanics (use of lifts, sliding boards, etc.)
Proper Positioning and Skin Care
Equipment (pumps, oxygen, vents, CPAP/BiPAP, monitors, wheelchairs, braces, splints)
Urinary Catheters
Wound or Ostomy Care
Medication Administration (by mouth, injection or feeding tube)
Blood Sugar Monitoring
Breathing Treatments
Rate your knowledge of basic anatomy and body systems, and how the body works together.
Do you know what the childhood developmental milestones are?
Do you know how to check a child's heartbeat?
Do you know what temperature (fever) is dangerous in a child?
Do you know what to do if a child has a seizure?
Do you know how to give eyedrops to a child?
Have you completed any other training that focuses specificially on care of medically fragile children?
If yes, what training have you completed?
Are you currently certified in ADULT and INFANT CPR?
If yes, when does it expire?
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