Respite Voucher Program Application

Respite Voucher Program Application Form
Name of Caregiver / Name of Family Member*
(the person applying for respite voucher funds)
Name of Respite Care Recipient*
(the person receiving respite services or personal supportive services)
Street Address for Primary Family Caregiver*
City for Primary Family Caregiver*
In which county in the 10-County Metro Atlanta region do you as the primary family caregiver reside?*

DeKalbFultonGwinnettCobbClaytonHenryRockdaleCherokeeDouglasFayette
State for Primary Family Caregiver*
Zip Code for Primary Family Caregiver*
Primary Phone Number*
Please enter a valid phone number.
Email*
example@example.com
1. Have you received funding from the ARC Respite Voucher or Personal Supportive Services Program in the past?*

YesNo
If yes, list all dates and amounts used.
If yes, verify that all information is current. I, Caregiver Name* confirm that all updated information has been included in this application. Caregiver Initials*
2. Under what circumstances are you as the primary family caregiver providing care to a loved one (care recipient)?*

Adult family member or other informal caregiver age 18 and providing care to individuals 60 years of age and olderAdult family member or other informal caregiver age 18 or older providing care to individuals of any age with Alzheimer's disease and related disordersOlder relatives, including parents, age 55 and older providing care to adults ages 18-59 with disabilities
3. What is your relationship to the respite care recipient, the person you are taking care of?*

Adult ChildSpouseSiblingOther
4. Are you the legal guardian for your loved one (care recipient)?*

YesNo
5. Do you, the caregiver, have any disabilities? If yes, please list*

YesNo
List All Disabilities
6. Do you, the caregiver, have any sensory impairments? If yes, click all that apply.

Vision ImpairmentLegally BlindHearing ImpairmentDeaf
7. Why are you requesting assistance through the Respite Voucher Program?*

A break from caregiving to attend to my needs (i.e., go on vacation, date night, go to the store)Increased support following hospitalization, rehab or to supplement care while loved one is on hospiceBridge increased level of care prior to move to assisted living, skilled nursing or other facilityOther
8. Please provide the name, address, and phone number for your loved one (respite care recipient). *
9. Who does your loved one, care recipient live with? Select ONE Option:*

AloneSiblingAdult ChildNiece/NephewParentOther Family MemberGrandchildSpouseAunt/Uncle
10. With what tasks or activities do you need assistance for your respite care recipient? (Read notes below and mark all that apply)*

BathingDressingTransferring/MobilityToiletingCompanionshipEatingTransportationMeal PreparationCleaning/LaundryShoppingAdult Day/Adult Day Health ProgramWeight Bearing
*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)
11. Will your loved one (Care Recipient) be aware and/or willing to accept care? Please note that refusal of care will result in immediate discharge from the program. The Caregiver will be responsible for providing payment to agency.*

YesNo
12. Are you currently using Homecare or Adult Day Health for your loved one, or the care recipient?*

YesNo
13. Which service do you currently pay for?

In HomeAdult Day Health Services
For Adult Day Health Services, please check off transportation mode:

MARTACaregiverUber/LyftAgency TransportationOther
14. Day(s) you plan to use respite services? Select all that apply:*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Please note there is a 4-Hour Minimum for services provided.*

AMPM
15. Do you have a Licensed Home Care Provider/Adult Day Agency for services identified that you plan to use?*

YesNo
If yes, please provide name of agency, contact name, and phone number of the provider? Please note, only providers applicants are currently or previously used will be accepted.
16. How did you hear about the Respite Voucher Program?*

Atlanta Regional CommissionJewish Family & Career Services WebsiteAgeWell Atlanta I&R ConciergeJF&CS StaffCounty AgencyFamily/FriendOther
Primary Family Caregiver Information
Date of Birth of Primary Family Caregiver*

MonthDayYear
Date
Age of Primary Family Caregiver*

18-2526-3637-4647-5960+
Gender of Primary Family Caregiver*

MaleFemaleOther
Marital Status of Primary Family Caregiver*

SingleMarriedDivorcedWidowedDomestic Partner
Total number of ADULT family members in Family Caregiver's household:*
Total number of CHILDREN (under 18 years) in Family Caregiver's household:*
Is the caregiver a Veteran?*

YesNo
Race/Ethnicity of Primary Family Caregiver*

African AmericanAsianCaucasianHispanic/LatinoMultiracialNative AmericanPacific IslanderOther
Respite Care Recipient Information
Name of Respite Care Recipient (the person receiving respite services)*
Address where the Respite Care Recipient will receive services: *
Date of Birth of Recipient:*

MonthDayYear
Date
Age of Recipient*

18-2526-3637-4647-5960+
Gender of Recipient*

MaleFemaleOther
Marital Status of Recipient*

SingleMarriedDivorcedWidowedDomestic Partner
Is the care recipient a Veteran?*

YesNo
Race/Ethnicity of Recipient*

African AmericanAsianCaucasianHispanic/LatinoMultiracialNative AmericanPacific IslanderOther
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)
Primary Disability or Special Need:*
Secondary Disability or Special Need (optional):
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.
I understand that the intention of the Respite Voucher Program at Jewish Family & Career Services (Aviv Older Adult Services) is to allow the primary family caregiver to get a break from providing care for their loved one by providing in home services or adult day care.*
Type your initials
I understand that the intention of the Personal Supportive Services Program at Jewish Family & Career Services (Aviv Older Adult Services) is to allow seniors residing in Henry or Douglas County to age in their homes.*
Type your initials
I understand that there are no breaks in services and funds must be used regularly. Breaks could include vacations, family in town, or hospitalization. Please note any breaks in services could result in being discharged from the program. *
Type your initials
I understand, as per The Atlanta Regional Commission, JF&CS and The Respite Voucher and Personal Supportive Services Program must meet its contract deliverables and responsibilities to its vendors. While respite is designed to support the ADL and IADL's, it is not designed to support chore services. It is designed to support the living area for the person receiving the care. Anything outside of laundry or light housekeeping, like dusting and vacuuming, and keeping the area of the care recipient clean, is not a part of respite. The agency has the responsibility to notify JF&CS Staff if the caregiver is requesting services that are not meeting the focus of this grant.*
Type your initials
I, the Caregiver, must agree to maintain the boundaries of the services and, if not, this program is not designed to meet my expectations. As a result, I understand that I will be discharged from The ARC JF&CS Respite Voucher and Personal Supportive Services Program.*
Type your initials
I understand that the service I receive from the Respite Voucher and Personal Supportive Services Program of Jewish Family & Career Services (Aviv Older Adult Services) are solely for services provided to the respite care recipient listed on this application and that these funds cannot be used for any other individual.*
Type your initials
I understand I must notify the agency and Mandy Rappoport as soon as possible with any changes in utilizing services.*
Type your initials
I understand my signature below authorizes a release of information for program purposes only.*
Type your initials
I, the family caregiver, understand that refusal of care, by my loved one/care recipient will result in immediate discharge from the program. I also understand that I will be responsible for providing the Homecare or Adult Day Health agency with payment for services provided. *
Type your initials
I confirm all information provided is current and up to date. *
Type your initials
I understand that this program provides payment directly to a licensed homecare or adult day health facility and does not offer compensation to me, as the applicant or family caregiver, for caregiving services . *
Type your initials
Jewish Family & Career Services administers the Respite Voucher and Personal Supportive Services 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.
Signature of Applicant (Primary Family Caregiver)*

Clear
Date*

MonthDayYear
Date
Print Name: Applicant (Primary Family Caregiver)*
File Upload*

Cancelof
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 (770) 677-9487.
Please provide:

Proof of Age for both the caregiver and care recipient: State Issued ID, State Issued Driver’s License, Birth Certificate, Passport, or Military ID.

Proof of Address for the caregiver: The documents must show your full name and current residential address.

P.O Boxes do not prove residency.

All documents must be dated within the past 30 days.

☐ Household Information – (Deed, Mortgage, Monthly Mortgage Statement, Residential Rental /Lease agreement)

☐ Utility bills (ex. water, gas, electricity, telephone/cell, cable, etc.)
☐ Motor Vehicle Information – (Vehicle registration or title, insurance policy or insurance card with address)
☐ Medical Statements (Medical or Health Bill)

All applicants, including those who are reapplying, are required to provide eligibility documents, from the items listed above.
Should be Empty:

Respite Voucher Program Application Form

Respite Voucher Program Application Form

Primary Family Caregiver Information

Respite Care Recipient Information