Thank you for your interest in the Caregiver Respite Program. Please carefully review the eligibility criteria for the program below.

The Atlanta Regional Commission grant requires Proof of Age for both the caregiver and care recipient: I.e.: state issued ID, driver's license, birth certificate, passport, or benefits documents. Also required is Proof of Address for the caregiver: I.e.: recent utility bill (electric, gas, water). You will be required to upload these documents/images at the time you submit this application.

Please note: we cannot provide respite funding for a loved one (care recipient) that is currently enrolled in a Medicaid waiver program (Elderly & Disabled Waiver Programs: CCSP or Source).

Unfortunately, these eligibility guidelines are firm, and we are not able to make exceptions. If you do not meet these eligibility guidelines and would like to learn more about other resources and programs for caregivers and older adults, please reach out to our AgeWell Atlanta Information and Referral line at 1.866. AGEWELL (1.866.243.9355).

Eligibility Guidelines:

1) Are you a family caregiver or other informal caregiver providing care to a loved one (care recipient) under one of the following circumstances?

• Adult family members or other informal caregivers age 18 and older providing care to individuals 60 years of age and older
• Adult family members or other informal caregivers age 18 and older providing care to individuals of any age with Alzheimer’s disease and related disorders
• Older relatives, including parents, age 55 and older providing care to adults ages 18-59 with disabilities

2) Do you (the caregiver) reside in the 10-County Metro Atlanta Region (Dekalb, Fulton, Gwinnett, Cobb, Clayton, Henry, Rockdale, Cherokee, Douglas, Fayette)?

3) Does your loved one (care recipient) currently reside outside of the following settings: personal care home, assisted living community, memory care community, continuum of care retirement community (CCRC), short-term rehab, skilled nursing facility/nursing home?

If you answered Yes to all three questions above, then you are eligible to apply for the Respite Voucher Program.

Please do not apply until you are ready to schedule in-home or out-of-home respite services for your loved one.

If you do not meet these eligibility guidelines and would like to learn more about other resources and programs for caregivers and older adults, please reach out to our AgeWell Atlanta Information and Referral line at 1.866.AGEWELL (1.866.243.9355).

*Please note that cleaning duties/responsibilities must be classified as light housekeeping and may only be done for care recipient

*Please note that this grant will not pay for transportation costs (mileage will be billed directly to the family caregiver)

Using the list below, please write the disability or special need in the appropriate location (if other, please specify)

Intellectual/Developmental Disability: Intellectual Disability, Autism

Physical/Orthopedic/Mobility Impairment: Multiple Sclerosis, Muscular Dystrophy, Cerebral Palsy

Sensory/Communication Impairment: Blind/vision impaired, Deaf/hard of hearing

Mental/Emotional/Psychosocial Impairment: Mental Illness, Mood/Personality Disorders

Degenerative Neurological Impairment: Dementia/Alzheimer’s, Parkinson’s, ALS

Neurological Impairment (nondegenerative): Stroke, Traumatic Brain Injury, Spinal Cord Injury

Medically Fragile/Frail Elderly

Other (please specify below)

Acknowledgements

Primary Family Caregiver: Please read and initial each item below.

Sign and date form before submitting the application
to Aviv Older Adult Services of JF&CS.

Jewish Family & Career Services administers the Respite Voucher Program to provide short-term funding for respite care services but does not provide these services directly or indirectly. I attest that the information included in this Application Form is true and accurate to the best of my knowledge. I understand that falsification of information will result in termination of services.

Please sign and email this form to caregiver@jfcsatl.org.

If you experience any problems with this application and/or have additional questions, please contact Mandy Rappoport at (470) 433-5957.

Please provide Proof of Age for both the caregiver and care recipient: I.e.: State issued ID, driver's license, birth certificate, passport, or benefits documents. Also required is Proof of Address for the caregiver: I.e.: recent utility bill (electric, gas, water).