Download a Basic Caregiver Class registration form. Or, you may complete the online application below.
Thank you for your interest in our program.
Please complete one registration form PER family member planning to attend. All information will remain confidential.
By submitting this form, I confirm that I wish to attend the two-day Family for Keeps® Basic Caregiver Course, a Dream House for Medically Fragile Children Program. I understand that, until receiving confirmation from a Dream House representative, I am not guaranteed a specific class date.
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.
| label | REGISTRATION FORM
Class Date: | *class_dates=textarea,40,2 | Enter class dates you are requesting
Name: | *name=input,40
Occupation: | *occupation=input,40
Email: | *email=input,40
Home Address: | *address=textarea,40,2
City: | *city=input,40
State: | *state=input,2
Zip: | *zip=input,9
County: | *county=input,40
Preferred Telephone: | *telephone=input
Highest Level of Education: | *education=input,40
How did you learn about this training? | How_did_you_learn_about=input,40
| label | Reason(s) for taking this course:
I am a biological parent or relative of a medically fragile/special needs child. | biological_family=check
I am a foster or adoptive parent of a medically fragile/special needs child. | foster_adoptive_family=check
I plan to be a foster or adoptive parent of a medically fragile/special needs child within the next six months. | plan_fosteradopt_mfc_6_months=check
I am a respite care provider who is now or would like to provide respite for a medically fragile child. | want_to_respite=check
I am a community or extended family member interested in assisting a family with a medically fragile child. | community_interest_yes=check
I am a foster parent with no experience or plans to care for a medically fragile child, but want to learn more. | current_foster_no_MFC_experience=check
Other - please explain: | other=textarea,40,2
How many children are in your care? | Number_children_in_care=input,5
How many are medically fragile? | mfc_number=input,5
If you are not already caring for a medically fragile child, are you considering doing so? | Considering_mfc_care=check
If you are a foster parent, with which agency are you affiliated? | agency_affiliation=input,40
What needs do you or your child have that would make it easier to provide care? | needs_required_to_help_situation=textarea,40,5
Please list the AGE and MEDICAL CONDITION(S) of your medically fragile child(ren). | age_diagnosis=textarea,40,5
| label | Please rank your current SKILLS KNOWLEDGE. '0' is no knowledge, '1' is some knowledge/experience wish to learn more, '2' have good knowledge or experience
Suctioning and Trach care | %suctiontrach=input,2
Feeding Tubes (G, J, NG, GJ) | %tubes=input,2
Proper Body Mechanics (lifting, transferring) | %bodymech=input,2
Proper Positioning and Skin Care | %skincare=input,2
Medication Administration (to children) | %meds=input,2
Breathing Treatments/oxygen therapy | %breath=input,2
Rate your knowledge of basic anatomy and body systems, and how the body works together. | %anatomy=input,2
Do you know what the childhood developmental milestones are? | milestones_yes=check
Do you know how to check a child's heartbeat? | heartbeat_yes=check
Do you know what temperature (fever) is dangerous in a child? | fever_danger=check
Do you know what to do if a child has a seizure? | seizure_yes=check
Do you know how to give eyedrops to a child? | eyedrops_yes=check
Have you completed any other training that focuses specificially on care of medically fragile children? | other_training_yes=check
If yes, what training have you completed? | training=textarea,40,5
Comments: | comments=textarea,40,5
Contact Me: | contact_yes=check
| formtype_mail=submit | Send form!
| html_enabled=hidden | 1
| subject=hidden | FFK Basic Registration
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