2024 Family Partnership Parent & Caregiver Retreat Registration

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SHCN Family Partnership will be hosting the 2024 Parent and Caregiver Retreat at Margaritaville Lake Resort, in Osage Beach, MO. The Retreat activities will start at 4 p.m. on Friday, September 13th, and commence at 3:30 p.m. on Saturday, September 14th.

This FREE event is designed for Missouri parents, legal guardians, and caregivers of children and youth, ages birth to 21, who have been identified as having a complex medical condition(s) and/or who are deaf/hard of hearing.

Please DO NOT provide any personal or sensitive information when filling out this form, such as a social security number, credit card, account number, etc.

Registration for the SHCN Family Partnership Parent and Caregiver Retreat includes hotel accommodations, sessions, meals, and exhibits. Only individuals who register will be given access to Retreat events.

Each individual attending the Retreat events must register.

Please do not register children (anyone under the age of 18), as a participant, or bring them with you to the sessions and/or meals. The SHCN Family Partnership is dedicated to providing a relaxing, fun environment for parents and caregivers who may not have resources to get away to escape the stressors of their everyday life. For this reason, we do not offer childcare, but instead provide a stipend to help offset family expenses.

*Online registration ends at 5:00 P.M. on June 30, 2024

Name:

Organization name (if applicable):

Home mailing address:

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County:

Phone number:

Email:

Would you like to add your email to the SHCN Family Partnership Listserv?

Yes

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Select your role as a Retreat Attendee of the child who has been identified as having a complex medical condition(s), and/or who is deaf/hard of hearing.

Parent

Family Member

Legal Guardian

Other

Professional (including paid caregiver)

Please identify your relationship

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Have you attended the SHCN Family Partnership Parent & Caregiver Retreat in the past?

Yes

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How many times?

Has your child or youth received services from the Bureau of Special Health Care Needs (Healthy Children and Youth (HCY), Children and Youth with Special Health Care Needs (CYSHCN) and/or SHCN Family Partnership (FP))?

Yes

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Check all that apply:

My Child has a physical disability

My child has a complex medical need(s)

My child is deaf or hard of hearing

My child has a developmental disability

Other

Please define other:

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Please let us know who you are representing. (This information helps us determine stipend eligibility and will not be used for any other purpose). List the child/children's names/diagnosis/age (You may include up to three children.)

1st Child's Name	1st Child's Age	1st Child's Diagnosis
2nd Child's Name	2nd Child's Age	2nd Child's Diagnosis
3rd Child's Name	3rd Child's Age	3rd Child's Diagnosis

Friday reception

Yes

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Saturday breakfast

Yes

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Saturday lunch

Yes

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Any dietary restrictions?

Yes

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If yes, please explain:

*Special requests will be taken into consideration, but cannot be guaranteed

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Do you have any accommodation requests?

Yes

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If yes, please check all that apply or explain in other:

Assistive listening device

Interpreter (ESL, ASL, Cued Speech or language)

Electronic or Braille handout

Roll-in shower

Toilet riser

Grab bars

Other

Other accommodation requests:

Please explain any other accommodation needs and be as specific as possible (i.e., accessible sleeping room, proximity to elevators, etc.) We will attempt to meet any request made in a timely fashion and within our logistical and financial resources. All requests must be received upon registration. Accessible rooms are limited and on a first-come, first serve basis.

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Please note: SHCN Family Partnership will provide one hotel room per family on Friday evening. Families are responsible for any additional accommodations.

I plan to room alone.

I will be rooming with someone.

I do not need a room for Friday evening.

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Please enter the name of the attendee you will be staying with

Note: If this individual will be attending the Retreat, and is over the age of 18, they must also complete a separate online registration.

Room preferences:

I need two double beds.

I can use a king size bed.

I do not have a preference

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Stipends are available for families to help offset family expenses necessary to attend the conference. Only one stipend is available per family. Professionals, including paid caregivers, do not qualify to receive the stipend.

Stipends will be distributed at the end of the event, upon submission of the required documents (which may include evaluations and/or surveys). Attendees must be signed in at the Retreat registration table by 8:00 a.m. Saturday morning and be present through the full day on Saturday to be eligible to receive the stipend. Questions regarding the stipend should be directed to Tonda Lain at Tonda.Lain@health.mo.gov or 1-800-451-0669.

Please select your stipend eligibility:

I am a parent/family member.

I am a professional/caregiver and do not qualify to receive the stipend.

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I understand that photographs and videos may be taken and utilized by Missouri Department of Health and Senior Services for educational and/or broadcast purposes. This includes uploading it on social media and/or the website.

* must provide value

I understand

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If you will be attending with another individual (over the age of 18) and they will be attending Retreat events, they must register as well.
For your comfort, please bring a sweater, jacket, or dress in layers as the temperature in the conference rooms can vary.

I understand I cannot register my children or anyone under the age of 18 to attend Retreat events, including meals.

Note: By selecting this, I agree that I will not register my children or anyone under the age of 18 to attend Retreat events, including meals. Attendees must present their Retreat name badge to receive meals.

* must provide value

I understand

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I understand completing a registration form does not guarantee me a spot at the Retreat. I further understand that I will be notified by a SHCN Family Partner prior to the Retreat on whether I was selected to attend the Retreat. I know there are a limited number of spaces for attendees.

* must provide value

I understand

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A credit card may be required by the hotel at the time of check-in to cover incidental charges or damages to the guest room (this does not include the guest room charge which is covered by SHCN Family Partnership).

Please forward questions to your SHCN Family Partner at FamilyPartnership@health.mo.gov or 1-800-451-0669.

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