Form 11 – Lodge Request for Professional Staff Participation

Step 1 of 2

Event(Required)

Lodge(Required)

Description of Event(Required)

CHEMPI Board of Trustees policy prohibits inviting client/family to attend President’s Visitations, DDGER Clinics and DDGER or Vice President’s Visitations

Date of Event(Required)

Time of Event(Required)

Number of Expected Attendees(Required)

Number of Staff Requested(Required)

Describe how staff/child will be asked to participate(Required)

Child & Family Requested(Required)

Yes

Request for child/family will be honored if possible.

Is the staff person's spouse invited?(Required)

Yes

Will Lodge be hosting staff/family for meals?(Required)

Yes

Is audio/visual equipment available?(Required)

Yes

How long is the presentation expected to last(Required)

Directions to the Lodge or location of event(Required)

Person in Charge(Required)

First Last Tiitle

Mailing Address(Required)

Street Address City State ZIP Code

Contact #(Required)

Lodge Address(Required)

Street Address City State ZIP Code

Lodge Phone(Required)

Name of Host (Person assigned to serve as host to staff and family)(Required)

First Last

SUGGESTIONS TO LODGES

If a child is requested, please note the following:
1. Schedule the appearance/child’s presentation early in the program so they may be excused before fatigue becomes a factor.
2. It is not always possible to present a child in braces or with specific problems; however, we will try to meet the lodge’s request as closely as possible.
3. A small gift for the child is welcome if the lodge wishes to give one; however, members are asked to refrain from giving the child money.
Please give careful consideration to the type of event to which the child is invited. A dance is usually a poor forum for a professional staff’s presentation. The prevailing mood is not conducive to the attentiveness that is necessary. The best format for these presentations is usually meetings in which the staff person has the undivided attention of the lodge members.
If a family is to attend the Lodge function, then the therapist will have the legal guardian complete CHEMPI Form #30 Client’s Lodge Consent Form prior to attending the function. If the legal guardian does not grant permission for the child/family to be photographed or their story published, then the Elks members need to be informed. The therapist who is in charge will be required to inform the Elks members of the family’s wishes. If a client participated in the event, a copy of Form #30 will be given to the Elks member who is in charge of the event.

Remember, the Therapists/Pediatric Vision Screeners are giving their own time for this event; every consideration should be given to them and the children.

To avoid last-minute complications in handling this request, you must submit this Form 11 to us a minimum of one month prior to your function.

Request Submitted By:(Required)

First Last Title

Date

SUGGESTIONS TO LODGES

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