Caregiver Educational Assistance Application

Caregiver Educational Assistance Application
Introduction:

Thank you for your interest in seeking educational assistance from The Kristina Butler Foundation. Our Foundation is dedicated to supporting professional caregivers who provide essential home care services to individuals in need. Please complete this application to help us assess your eligibility for our Caregiver Support Program.

Application Guidelines:
- Applications are processed within 30 business days of cycle close. Submission does not guarantee assistance due to limited resources.
- For detailed assistance policies, please refer to The Foundation’s Assistance Policy here.
Cycle Information:
- During this cycle The Kristina Butler Foundation will be awarding a maximum of $750 per selected applicant.
- Application submission period for this cycle will be open from February 15, 2025 to March 23, 2025 11:59 P.M. EST
I am requesting support for*

MyselfSomeone else
Your Contact Information
What is your name? *

First NameLast Name
What is your phone number?*
Please enter a valid phone number.
What is your email address?
example@example.com
What is your relationship to the person you are requesting assistance for?*
To ensure we best support caregivers, we require them to complete their own application. Please send this application to the caregiver directly. Paper applications are available upon request by emailing hello@kristinabutlerfoundation.org. Paper applications can also be mailed to:

The Kristina Butler Foundation, Inc.

P.O. Box 17482

Sarasota, FL 34276
Personal Information of the Caregiver Needing Assistance:
Full Legal Name*
Include all applicable: First, Middle, Last, Suffix
Date of Birth*

MonthDayYear
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Best time to call

MorningAfternoonEveningAnytime
Email
example@example.com
Eligibilty Criteria:
Have you, or anyone in your household, previously received support from the Kristina Butler Foundation?*

YesNo
Have you, or anyone in your household, previously requested support from the Kristina Butler Foundation?*

YesNo
Name of the person who previously requested support *
Are you directly related to a current employee or board member of The Kristina Butler Foundation? This includes spouses, parents, children, siblings, or any other close relatives.*

YesNo
Eligibility Requirements for Caregivers:

To be considered for educational assistance, applicants must:
1. Be employed as a professional caregiver by a professional agency or home health / home care agency.
2. Reside in the United States.
3. Be at least 18 years of age at the time of funding.
4. Demonstrate financial need.
5. Provide proof of caregiving responsibilities and employment status.
6. Successfully pass a background check in accordance with applicable laws.
Do you believe you meet all the above eligibility requirements?*

YesNo
Caregiving Experience

Please answer the following questions about your caregiving experience.
Do you have experience as a caregiver?*

YesNo
Are you a:*

Professional caregiver (employed by an agency or individual)Family caregiver (providing unpaid care to a friend or relative)Other
Name of your Employer:*
Are you a certified / registered caregiver?*

YesNo
Please provide the certification number and state of issuance:*
Caregiver Status: When were you a caregiver?*

Currently a caregiverWithin last 30 daysWithin last 3 monthsWithin last 6 monthsWithin last 12 monthsOver a year agoNever
Duration of caregiving experience*

5+ years3-5 years1-3 years7-12 months0-6 monthsNone
Average number of hours you provide care weekly:*

31-40+ hours per week21-30 hours per week11-20 hours per week6-10 hours per week1-5 hours per week0 hours per week
Type(s) of care you have provided (Select all that apply):*

Bathing, grooming & dressingMobility Assistance: ambulation, transferring, etc.Toileting & continence careMedication reminders / managementHousekeepingShopping / errandsTransportationCompanionship and emotional supportMeal preparation / feedingExercise / range of motionSafety AssistanceNone of the aboveOther
Conditions you have cared for (Select all that apply):*

Cognitive Limitations: Alzheimer's Disease or DementiaChronic Illness: Cancer, diabetes, heart disease, etc.Mental Health ConditionsMobility issues, arthritis, osteoporosisParkinson's DiseaseStrokeHearing Impairment / DeafSpeech ImpairmentVision Impairment / BlindParalysisHospice careSkilled Care ServicesNone of the aboveOther
Proof of Caregiving
Attach a copy of your latest pay stub or letter of employment from your employer on company letterhead.*

If you have any issues uploading documentation, email hello@kristinabutlerfoundation.org
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Situational Questions
How do you contribute to your community outside of your caregiving role? This could include volunteering your time, participating in community events, or simply being a good neighbor.*

I occasionally volunteer when opportunities arise.I am willing to volunteer but haven’t had many opportunities.I regularly volunteer to help others in need.I haven't done any volunteering.
What kind of feedback do you receive on your contributions or achievements in your caregiving role? This could include awards, recognition from colleagues or supervisors, or positive feedback from clients or their families.*

I receive some positive feedback.I receive mostly negative feedback.I have not received feedback but am open to receiving feedback.I receive consistent positive feedback.
How can you be counted on to fulfill your caregiving responsibilities?*

Always reliable.Generally reliable.Working to improve reliability.Difficulty meeting commitments.
How would you handle a situation where you made a mistake while caregiving?*

I would take responsibility, communicate openly and seek guidance to resolve the situation.I would acknowledge the mistake and learn from the experience.I would inform someone about the mistake but might hesitate to take full responsibility.I would find it difficult to admit mistakes.
Imagine you are helping someone who seems down. What would you do first?*

Ask them directly what’s wrong and offer advice.Offer a distraction or activity to take their mind off things.Listen attentively and try to understand how they’re feeling.Say something like, “It sounds like you’re feeling sad/upset. Is there anything I can do to help?
Professional Reference Information

Provide contact information for a professional reference who can verify your caregiving experience
Reference's Full Name*
Reference's Phone Number*
Please enter a valid phone number.
Your relationship to this professional reference contact:*
I authorize the Kristina Butler Foundation to contact this reference. (Please note, in order to determine your eligibility, we will need to contact your reference)*

YesNo
Needs Assessment:
How many dependents do you support?*
What is your total household income?*

Below $25,000$25,000 - $49,999$50,000 - $59,999$60,000 - $74,999$75,000 - $84,999$85,000 - $94,999$95,000 - $104,999$105,000 - $114,999$115,000 - $124,999$125,000+
Name of school you wish to attend:*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Certification / degree you wish to receive or program name you wish to complete:*
What is the anticipated cost of the program / certification?*
Please note, entering an amount does not guarantee this amount will be issued. We will verify costs through the school. Additional criteria from your application will help us determine the amount you will receive, if eligible.
Tell Us About Your Caregiving Journey! (500 words or less)

In a few sentences, tell us:
- Why you care: Briefly explain why you became a caregiver and what motivates you to provide care.
- Your goals: What skills or knowledge are you hoping to gain through education? What is your main goal for receiving additional education?
- Making a difference: How will this education help you better care for the individuals you support?
Write you answer below (Answers should be at least 5 words and up to 500 words maximum)*

0/500
You are welcome to upload any additional documents that should be considered in your application.

EX: Letter of recommendation, volunteer certificates, etc.
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Electronic Signature:

By typing your name below, you agree that:
1. The information you provided in this application is truthful and complete to the best of your understanding.
2. Submitting this application does not guarantee funding from the Kristina Butler Foundation.
3. Any awarded funds will be used solely for the educational expenses outlined in this application.
4. Proof of payment or program completion is required and must be submitted in a timely manner.
5. You have reviewed and agree to the eligibility criteria.
Electronic Signature [Type your full name here:]*
First Name, MI, Last Name, Suffix
Calculation
Should be Empty:

Caregiver Educational Assistance Application

Your Contact Information

Personal Information of the Caregiver Needing Assistance:

Eligibilty Criteria:

Caregiving Experience

Proof of Caregiving

Situational Questions

Professional Reference Information

Needs Assessment: