Play for the A's Application Form

Play for the A's Application Form

Play for the A's provides a break from caregiving, for an individual who is caring for a loved one with Alzheimer's or dementia. The individual may be awarded a "Gift of Time" - several hours to meet their own needs (e.g. for self-care, to see their own doctors, to visit a friend, to dine out, to attend a wedding, etc). The Community's Foundation can provide this service, because of community leaders like Jef Hewlings. Jef started the Play for the A’s fund to honor his parents. Jef's Father cared for a loved one with Alzheimer’s. And, Jef knows how physically and emotionally draining caregiving can be.
Eligibility Requirements. Please select all that apply:

Caregiver resides in Delaware County, PACaregiver cares for a loved one with Alzheimer's or dementia
Are you:

A Caregiver, Applying for YourselfSomeone Else, Nominating a Caregiver
Name of Nominator*

First NameLast Name
Phone Number of Nominator*

Area CodePhone Number
Name of Patient*

First NameLast Name
Name of Caregiver*

First NameLast Name
Caregiver's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver's Phone Number*

Area CodePhone Number
Caregiver's Email Address*
example@example.com
Does the Caregiver currently have help from a home health agency?*

YesNo
Tell us about the Caregiver's responsibilities:*
What would the Caregiver do with a 3-5 hour break?*
Should be Empty: