Application For Respite Care Program
 

 (Please Print or Type)
 

PARENT/FAMILY MEMBERS NAME:________________________________________

ADDRESS:____________________________________CITY:____________________

ZIP CODE:__________HOME PHONE:____________WORK PHONE:_____________
 

The child or adult’s diagnosis and source of diagnosis must be listed above. Documentation of the child or adult’s diagnosis or adoption must accompany this application form. A copy of any document containing the diagnosis and name of the physician or therapist issuing the diagnosis is sufficient for children or adults with a developmental disability, and children with developmental delays or chronic medical conditions. If the child has a serious emotional disturbance or the adult has a severe and persistent mental illness, a summary evaluation form available from the Department of Human Services (1-800-265-9684) should also be completed by the therapist and returned with the application.
 

Family member’s relationship to child or adult needing care: _____________________________________________________________________________.

Are any of the children in your family adopted?_____________(yes or no).

Does your child or adult family member reside in your home the majority of the year?____(yes or no)

If no, please explain:__________________________________________________________________.

Briefly describes how your child's or adult family member's needs affect him/her and your family on a daily basis:

A qualifying family may receive services up to $550 for one eligible child or adult per year, and $200 for each additional eligible child or adult, up to a maximum of $950 per year, per family. What amount of respite care do you request for your family for this year? ______________________

I understand that for a child or adult to be eligible for the Respite Care Program they must have a developmental delay (children under age 5 only) or disability, a serious emotional disturbance, a severe or persistent mental illness, a chronic medical condition (children only), traumatic brain injury or be adopted; and must reside within the a family members’ home.

I hereby attest that my child(ren) or adult family member meets the eligibility requirements of eligibility for the Respite Care Program.

SIGNATURE________________________________________________DATE______________