Application | ACC Lifespan Respite Programs

Lifespan Respite Program Overview

The Arizona Caregiver Coalition (ACC) administers the Lifespan Respite grant in partnership with the Arizona Department of Economic Security (DES). Funding comes from the Administration for Community Living (ACL).
Caregivers are defined as an adult family member or individual who:
- Has a significant relationship with their loved one (CARE RECEIVER)
- Provides a broad range of assistance to a care receiver with a chronic or other health condition, disability, or functional limitation
- Provides constant care to care receiver that cannot be left alone.
Program Qualifications
1. Caregivers/care recipients must not be receiving other paid respite services paid with federal, state or insurance funds.
2. Caregiver must live full-time with or within 5 miles of the care recipient.
3. Care recipient must require constant care and assistance with 2+ daily living activities.
Program Overview

Care Program (click for more information)
Care Program

The Arizona Caregiver Coalition offers a reimbursement-based voucher to help family caregivers access various forms of respite support. Caregivers can use the voucher across several categories, depending on their needs:
- Informal Respite Provider - Reimbursement for hiring a trusted friend, family member, or neighbor (age 18 or older) to provide temporary care. The provider must not live in the same household as the care recipient.
- Recreational Activities - May be used for the caregiver alone or shared with the care recipient. Eligible activities include zoo memberships, art or yoga classes, museum passes, and other recreational outlets that promote caregiver well-being.
- Vacation Respite - Covers respite care costs while the caregiver is on vacation or reimburses specific travel-related expenses (e.g., flights, hotels) with documentation of care provided for the care recipient during that time.
- Education & Training - Supports the cost of educational programs to improve caregiving skills. Examples include CPR/First Aid certification, attendant care training, or specialized programs like the COPE Program through Oakwood Creative Care (with Oakwood referral).
- Home Modifications & Assistive Technology - Helps fund items that improve safety or accessibility in the home, such as grab bars, wheelchair ramps, sensory products, or hearing aids.
- Emergency Respite - Assists caregivers facing a sudden personal or family emergency that prevents them from providing care. Funds can be used to hire respite support during emergencies such as hospitalizations or out-of-state family crises.
Funding Levels Available:
- $599
- $2,400

Partners Program (click for more information)
Partners Program

The Arizona Caregiver Coalition (ACC) collaborates with Adult Day Health Centers and Social Model Day Clubs to provide 150 hours of respite care to eligible family caregivers. This program supports those caring for someone over the age of 18 with a physical disability, developmental disability, or Alzheimer’s/dementia.
- Approved caregivers may use their service hours throughout a one-year period.
- Caregivers are responsible for selecting, coordinating, and enrolling with a participating respite care provider.
- ACC pays the provider directly on behalf of the caregiver.
Please note: Our partners will have their own onboarding process that will need to be completed to fully enroll in this program. ACC is not liable for any actions taken by the partner organization.
- List of Partner Organizations (ADHC & SMDC)
- Lista de organizaciones asociadas (ADHC y SMDC)

Required Documentation (click for more information)

Documentation Required by Program

Form Type	Partners	Care Voucher $599	Care Voucher $2,400
Identification (for both Caregiver & Care Recipient)	Yes	Yes	Yes
Medical Needs Form	Yes	Yes	Yes
W-9 Tax Form for Caregiver	No	No	Yes

How to Submit Documentation:

Attach/upload - Upload a photo or scanned copy at the end of this application. Accepted formats: JPG, PNG, PDF.
Email: info@azcaregiver.org
Mail: Arizona Caregiver Coalition, PO Box 21623, Phoenix, AZ 85036

___________________

Identification: Caregivers must provide a Government ID with photo and address (such as Driver’s License) for themselves and the care recipient.

For care recipients under the age of 18, a birth certificate, guardianship paperwork, or student ID is acceptable.
If address on IDs does not match the address in the application, a proof of address must be provided, such as a utility bill or rental agreement.

Medical Needs Form: Must be completed for the care receiver by a medical professional, case manager, or social worker. | Download here

W-9 Form: If applying for $2,400 Respite Voucher, caregiver must provide an updated W-9. | Download here

Lifespan Respite Program Application

Care/Voucher Program
Which program(s) are you interested in?*

Respite Voucher $599 per yearRespite Voucher $2400 per year with Caregiver IRS W-9 formEmergency Respite (must document need)COPE Program with Oakwood Creative Care (with referral)Not sure yetOther
Can you demonstrate a financial hardship. Examples include a denial letter from AZ Long Term Care Services or a public benefit award letter (SNAP, TANF, WIC, etc...).*

YesNo
Additional Comments:

Lifespan Respite Program Application

Partners Program

Please READ CAREFULLY and mark each item after reading:*

	I understand
Arizona Caregiver Coalition is responsible only for authorizing clients in the Partners Program. The caregiver is responsible for selecting, screening, and arranging care with desired Agency/Facility.
Arizona Caregiver Coalition and the Arizona Department of Economic Security, Division of Aging and Adult Services, will not be held responsible for any actions taken by the Agency/Provider I choose.

What partner service(s) are you interested in?*

Adult Day Health Center / Social Model Day ClubIn-Home Care Agency (prioritized for caregivers with financial need or those in underserved areas)
Name of desired ADHC / SMDC
* If unknown, please leave blank.
Phone Number of desired ADHC / SMDC
Please enter a valid phone number.
Name of desired In-Home Agency
Phone Number of In-Home Agency
Please enter a valid phone number.

Lifespan Respite Program Application

Signature

Please READ CAREFULLY and mark each item after reading:*

	I have read and understand.
Completion of this application does not guarantee that I will be eligible for the Respite Program(s).
Caregiver agrees to complete application in its entirety, including an Exit Interview upon completion of services.
Caregiver is responsible for any balance due if hours or funds are exceeded.
I authorize the Arizona Caregiver Coalition to share personal information on behalf of myself and the care recipient for the purpose of coordinating supportive care, managing billing, and contributing to advocacy or research efforts.
I understand that ACC will take necessary precautions to maintain confidentiality. If I have any concerns, I will contact ACC promptly.

Print your name again*

First NameLast Name
My Signature on this form signifies that all information provided on this form and during any other assessments conducted by the Arizona Caregiver Coalition and the Caregiver Resource Line is truthful and accurate. *

Clear

Supporting Documentation

Documentation Required by Program

Type	Partners	Care Voucher $599	Care Voucher $2,400
Identification (for both Caregiver & Care Recipient)	*Yes*	*Yes*	*Yes*
Medical Needs Form	*Yes*	*Yes*	*Yes*
W-9 Form for Caregiver	No	No	*Yes*

How to Submit Documentation:

Attach/upload - Upload a photo or scanned copy below. Accepted formats: JPG, PNG, PDF.
Email: info@azcaregiver.org
Mail: Arizona Caregiver Coalition, PO Box 21623, Phoenix, AZ 85036

Required Documentation (click for more information)
Both Programs | Identification: Caregivers must provide a Government ID with photo and address (such as Driver’s License) for themselves and the care recipient.
- For care recipients under the age of 18, a birth certificate, guardianship paperwork, or student ID is acceptable.
- If address on IDs does not match the address in the application, a proof of address must be provided, such as a utility bill or rental agreement.
Both Programs | Medical Needs Form: Must be completed for the care receiver by a medical professional, case manager, or social worker. | Download here

Care Voucher Program Only | W-9 Form: If applying for $2,400 Respite Voucher, caregiver must provide an updated W-9. | Download here

How would you like to submit your documentation?

	Method
Identification (Caregiver and Care Recipient)
Medical Needs Form
W-9 (if applicable)

Supporting Documentation
Identification (Caregiver & Care Recipient)

Please upload: Caregiver and Care Recipient Identification + address verification (if applicable) | required for all programs
Cancelof
Medical Needs Form

Please upload: Medical Needs Form | required for all programs
Cancelof
Caregiver W-9 (if applicable)

Please upload: W-9 (if applicable) | required for Care Voucher $2,400
Cancelof
Documentation of Financial Hardship (if applicable)

Please upload: Documentation of Financial Hardship (if applicable)
Cancelof
Additional Comments:
Should be Empty:

	Yes	No	Unknown
Arizona Long Term Care (ALTCS)
Area Agency on Aging (AAA) Respite (ADHC or In-Home)
Hospice Medicare Benefits with Respite in a Facility
Veteran's Administration (VA)
Developmental Disability (DDD) Services
Other State or Federally Funded Programs/Insurance
I pay for respite myself

	Yes	No	Unknown
Arizona Long Term Care (ALTCS)
Hospice Medicare
Veteran's Administration (VA)
Developmental Disability (DDD) Services

	Yes	No
Personal hygiene, bathing, grooming, oral care
Dressing (making clothing choices and ability to dress oneself)
Eating (feeding the person, not necessarily preparing food)
Maintaining continence (help using the bathroom)
Transferring (moving from seated to standing or help in/out of bed)
Medication management
For children: Do they need special care beyond regular parenting? (Mark 'No' if this does not apply.)
Other

	Good	Fair	Poor
Medical status
Emotional status

	Yes	No
3.1 - Felt cut off from your family/friends?
3.2 - Felt overwhelmed?
3.3 - Had trouble falling asleep, staying asleep, or waking up too early in the morning?
3.4 - Noticed your eating habits worsened as a result of your caregiving?
3.5 - Been frustrated or angry as a result of your caregiving?
3.6 - Often felt sad or depressed?
3.7 - Often felt nervous or anxious?
3.8 - Had crying spells or often felt like you needed to cry?

Lifespan Respite Program Overview

Program Qualifications

Program Overview

Care Program

Partners Program

Lifespan Respite Program Application

Lifespan Respite Program Application

Lifespan Respite Program Application

Lifespan Respite Program Application

Lifespan Respite Program Application

Caregiver Assessment Tool (CAT)

Lifespan Respite Program Application

Supporting Documentation

Supporting Documentation