Campus Visitation Request Form 2024

1
Name of your loved one* This field is required.
First Name
Last Name
2
Springbrook Program* This field is required.
Student at the School at Springbrook
3
Your loved one’s Springbrook Home location* This field is required.
Highland
Hilltop
LeChase
McDowell
Scriven
Snell
Sunshine
Susquehanna
Taylor
Wright
4
Are you submitting this form for* This field is required.
Yourself
On Behalf of Someone
5
Name of person completing this form* This field is required.
First Name
Last Name
6
Email of person completing this form* This field is required.
example@example.com
7
Phone Number of person completing this form* This field is required.
Area Code
Phone Number
8
Name of the person for whom you are completing this form
First Name
Last Name
9
Email Address of the person for whom you are completing this form
example@example.com
10
Phone Number of the person for whom you are completing this form
Area Code
Phone Number
11
Type of Visit* This field is required.
In-Home Room Check
On Campus
Off Campus Home Visit
12
Preferred Room Check Date
Date
Month
Day
Year
13
Preferred Room Check Time9:00 AM - 5:00 PM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
14
I understand and will notify the house if my child or loved one is exposed to COVID, the Flu or is returning with any symptoms of either (fever, cough, sore throat, etc).
15
Preferred Date of Visit - First Choice
Date
Month
Day
Year
16
Preferred Time of Visit - First Choice9:00 AM - 5:00 PM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
17
Preferred Date of Visit - Second Choice
Date
Month
Day
Year
18
Preferred Time of Visit - Second Choice9:00 AM - 5:00 PM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
19
Preferred Date of Visit - Third Choice
Date
Month
Day
Year
20
Preferred Time of Visit - Third Choice9:00 AM - 5:00 PM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
21
Preferred Location
Indoors at the Family Engagement Center
Outdoor Tent Visit
22
Preferred Start of Visit Date
Date
Month
Day
Year
23
Preferred Pickup Time9:00 AM - 5:00 PM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
24
Preferred End of Visit Date
Date
Month
Day
Year
25
Preferred Visit Drop off Time9:00 AM - 5:00 PM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
26
I understand that Springbrook will not provide transportation to, from, or during my scheduled offsite visit* This field is required.(Does not include planned Springbrook van trips)
YESNO
27
I understand that Springbrook will not provide staffing support to, from, or during my offsite visit (regardless of the length of the visit)* This field is required.(Does not include planned Springbrook van trips)
YESNO
28
Is this a van run?
Yes
No
29
Type of van run:* This field is required.Select the type of van run. If other than Springbrook or School District, type the company name in Other.
Springbrook
School District
Other
30
Additional NotesPlease share any additional notes for your visit below.
Huge
Large
Normal
Small
Ok
Ok
31
By clicking Submit, I verify the accuracy of the information contained in this form.
Should be Empty: