Dementia Caregiver Respite Grant Form Click Here To Learn About This Grant "*" indicates required fields Step 1 of 3 33% Caregiver Information(unpaid person providing care to patient)Caregiver First Name* Caregiver Middle Name* Caregiver Last Name* Caregiver Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Caregiver Age* Caregiver Gender* Female Male Gender Identity: Caregiver Physical Home Address* Caregiver City* Caregiver State* Caregiver Zip* Caregiver County* Caregiver Mailing Home Address* Caregiver City* Caregiver State* Caregiver Zip* Caregiver County* Caregiver Phone* Caregiver Email* Caregiver Marital Status* Married Divorced Separated Single Widowed Caregiver Race* White Black/African American American Indian Asian Hispanic Other Caregiver Military Status* Retired Active Duty Veteran None Caregiver Ethnicity* Hispanic or Latino Not Hispanic or Latino Caregiver Relationship to the patient* How many hours of care do you provide daily?* How did you hear about this grant* Caregiver Employment Status* Employed Unemployed Caregiver Annual Household Income* Have you received a respite assistance grant in the past 12 months?* Yes No If so, from where?* For what kind of respite assistance are you applying* In-Home Care Adult Daycare Short-Term Facility Stay Are their any individuals, other than you, with whom we may share grant information? Please list in the space below* Care Recipient (Patient) InformationCare Recipient First Name* Care Recipient Middle Name* Care Recipient Last Name* Care Recipient Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Care Recipient Age* Care Recipient Gender* Male Female Care Recipient Gender Identity: Care Recipient Physical Home Address* Care Recipient City* Care Recipient State* Care Recipient Zip* Care Recipient County* Care Recipient Mailing Home Address* Care Recipient City* Care Recipient State* Care Recipient Zip* Care Recipient County* Care Recipient Phone* Care Recipient Email* Marital Status of Care Recipient* Married Divorced Separated Single Widowed Race of Care Recipient* White Black/African American American Indian Asian Hispanic Other Ethnicity of Care Recipient* Hispanic or Latino Not Hispanic or Latino Military Status of Care Recipient* Active Duty Retired Veteran None Patient Diagnosis* Does the patient live alone* Yes No Patient Primary Speaking Language* Has the patient recieved/currently utilizing and DHS Waiver or State Plan Service Programs?* Pre-Funding SurveyPlease rate the level of burden paying out-of-pocket for respite care is on your family* 1 2 3 4 5 Please rate the level of ease in applying for this grant* 1 2 3 4 5 Please rate your current stress level* 1 2 3 4 5 Have you received respite prior to applying for this grant?* Caregiver SignatureSignature of Caregiver*Date* Consent* I agree and understand that by signing electronically, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement
