Student Intake form

Current year:

Major:

How did you hear about the Time Out Program?:

Do you have access to a car? (Note: having access to a car is not a requirement):

Yes

No

Do you have any problems working in a home that has pets?:

no

yes

Would you be comfortable working with a person who smokes?:

no

yes

Have you ever been convicted of a crime?:

no

yes

Please check the population(s) you wish to provide respite care services to:

Older Adults

Developmental Disabilities

Hospice

No preferenece

Will your respite care work be used to fulfill an academic practicum requirement?:

no

yes

Would you consider volunteering your time to help a family?:

no

yes

Do you have a Temple PHEAA Work Study Grant?:

Yes

No

Not sure