• Respite Voucher Program Application Form

    Aviv Older Adult Services of JF&CS
  • Thank you for your interest in the Caregiver Respite Program. Please carefully review the eligibility criteria for the program below. 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 answer Yes to all three questions above, then you are eligible to apply for the Respite Voucher Program. Please complete the application.

    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).

  • Respite Voucher Program Application Form

  • Primary Family Caregiver Information

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  • Respite Care Recipient Information

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  • 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.

  • Clear
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  • 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.

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