Respite Programs

Lola’s Round Table’s Respite Programs & Services

Learn about the Respite programs Lola’s Round Table offers. Click the buttons below to apply to our Respite programs and our new Summer Youth Pilot Program.

Apply for Lola’s Summer Youth Pilot Program (High School Students Ages 15-21)Apply for Lola's Respite Programs

Current Programs

Weekday Respite Program

Monday – Friday: 9:30am – 3:30pm

Pick up and drop off provided at no extra cost between 8:00am – 9:30am & 3:30pm – 5:00pm
Occasional lunch program
Activity costs covered

*Wait list available when days are full

Lola’s Summer Youth Pilot Program (High School Students Ages 15-21)

*Please note: this program has limited spots. Filling out an application does not guarantee a spot in the summer youth program. Once applications are submitted you will be contacted for an in person meeting. We will review and you will be contacted if your application has been accepted for the program.

Lola’s Summer Youth Pilot Program Application

Applicant Name(Required)

First Last

Guardian Name(Required)

First Last

Age(Required)

Please enter a number from 1 to 110.

Birthday(Required)

MM slash DD slash YYYY

Email(Required)

Phone(Required)

Address(Required)

Street Address City Province Postal Code

Preferred Method of Contact(Required)

Text

Call

Current School(Required)

*Can potentially be paired with others who attend the same school

Primary Diagnosis(Required)

All Other Diagnosis

Will you family member require medication administration?(Required)

Yes

List Medications(Required)

Does your family member experience seizures?(Required)

Yes

List Types(Required)

Does your family member have allergies?(Required)

Yes

List Allergies(Required)

Additional Medical Information

Mobility(Required)

Good

Unsteady

Depth perception

Requires assistance

Visibility(Required)

Good

Poor

Has glasses

Auditory(Required)

Good

Poor

Hearing impaired

Selective listening

Requires people to repeat

Are there environmental factors to consider for your family member?(Required)

Yes

Please explain what environmental factors could trigger anger, fear, excitement and overstimulation?(Required)

Behavioural

Please list any behaviour challenges below that we should be aware of (ex. hitting, biting, throwing objects, self-injurious, flight risk).

Dietary

Please list any dietary challenges we should be aware of (ex. foods to avoid, food consistency: cut up, minced, puréed).

Safety

Please list any safety related challenges we should be aware of (ex. safety awareness, stranger danger, crossing the street, etc.).

Communication-Receptive(Required)

How does your family member understand communication?

Communication-Expressive(Required)

How does your family member communicate?

Personal Care(Required)

Please list anything we should know about your family member's personal care (ex. they are independent, they need some assistance with bowel movements, they require complete assistance, they wear a guard/brief, etc.).

Personal Finance(Required)

Please list anything we should know about your family member's personal finance (ex. they understand how to handle money, they have little to no understanding, they can hold their own wallet, etc.).

Special Protocols

Please list any special protocols below (ex. missing person, behavioural, emotional, boundaries, etc.).

Likes(Required)

Please list what your family member likes.

Dislikes(Required)

Please list what your family member dislikes.

Fears(Required)

Please list any fears your family member has.

3 + 9 =(Required)

(After entering the correct answer in the box above, the Submit button will appear.)

Name

This field is for validation purposes and should be left unchanged.

Future Programs

Weekday Respite Program

Monday – Friday: 9:30am – 3:30pm

Pick up and drop off provided at no extra cost between 8:00am – 9:30am & 3:30pm – 5:00pm
Occasional lunch program
Activity cost not included (temporary)

*Wait list available when days are full

Weekend Overnight Respite

Friday – Sunday

All meals included
No pick up or drop off

Summer Youth Program (Starting Summer 2023)

July & August (Monday, Wednesday, Friday): 9:30am – 3:30pm

No pick up or drop off offered
Occasional lunch program
Activity cost not included (temporary)

*Must have a minimum of 3 people to run the program

Apply for Lola’s Respite Programs

Fill out the New Applicant form below to apply for Lola’s Respite Programs.

Name of Applicant(Required)

First Last

Name of Parent / Guardian(Required)

First Last

Email(Required)

Phone(Required)

Preferred method of contact(Required)

Call

Text

Primary Diagnosis(Required)

All other diagnosis (if applicable)

Age of Applicant(Required)

Applicant's Birthday(Required)

MM slash DD slash YYYY

Will applicant require medication administration while at Lola's?(Required)

Yes

Yes, please administer medication while at Lola's.(Required)

Please list the name of medication(s), dose(s) required, route(s) and time(s).

Does the applicant have seizure activity?(Required)

Yes

Yes, the applicant has seizure activity.(Required)

Please explain the type of seizure and protocol needed.

Allergies

Please list any non-threatening allergies and/or life threatening allergies, along with any protocols needed (if applicable).

Requirements / Considerations

Mobility(Required)

Does the applicant require assistance with mobility while at Lola's?

Yes

Visual(Required)

Are any visual accommodations needed at Lola's?

Yes

Auditory(Required)

Are any auditory accommodations needed at Lola's?

Yes

Environmental(Required)

Are any environmental accommodations needed at Lola's?

Yes

Personal Care(Required)

Will the applicant require any kind of personal care while at Lola's?

Yes

Safety(Required)

Does the applicant understand safety awareness?

Yes

Communication-receptive(Required)

Does the applicant understand what is being said to them?

Yes

Communicative-expressive(Required)

How does the application communicate with others? Please explain below:

Dietary(Required)

Does the applicant have any dietary restrictions?

Yes

Please explain what dietary considerations/restrictions the applicant has:(Required)

Behavioural(Required)

How does the application express themselves behaviourally towards others and themselves? Please explain below:

Immunizations up to date (including COVID-19 vaccine)?(Required)

Is the applicant's immunizations (including the COVID-19 vaccine) up to date?

Yes

No, the applicant's immunizations are not up to date.(Required)

Please list immunizations applicant has had below:

8 + 3 =(Required)

(After entering the correct answer in the box above, the Submit button will appear.)

This field is for validation purposes and should be left unchanged.

Lola’s Round Table’s Respite Programs & Services

Current Programs

Weekday Respite Program

Lola’s Summer Youth Pilot Program (High School Students Ages 15-21)

Lola’s Summer Youth Pilot Program Application

Future Programs

Weekday Respite Program

Weekend Overnight Respite

Summer Youth Program (Starting Summer 2023)

Apply for Lola’s Respite Programs

Requirements / Considerations

Contact Us

Payment Methods

Additional Info

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