Caregiver Dementia Care Certification Application

Caregiver Dementia Care Certification Reimbursement Application
Introduction:

Thank you for your interest in the Dementia Care Certification Reimbursement Program offered by The Kristina Butler Foundation. This program is designed to support professional caregivers and the organizations that employ them by providing financial assistance for completing an approved Dementia Care Certification course.

This certification helps equip caregivers with the specialized knowledge and skills needed to provide compassionate, informed care to individuals living with Alzheimer’s and other forms of dementia.

Please complete this application to help us assess your eligibility for reimbursement of training costs associated with a qualifying program.

Application Guidelines:
- Reimbursement is available to caregivers or their employers who apply on their behalf
- Each caregiver must have a separate application, even if submitted by the same employer
- Proof of training completion and documentation of cost per caregiver must be submitted before reimbursement can be issued
- Applications will be reviewed and processed within 30 business days after the funding cycle closes
- Submission does not guarantee funding due to limited resources
- For detailed assistance policies, please refer to The Foundation’s Assistance Policy here.
Cycle Information:
- During this funding cycle, The Kristina Butler Foundation will award a total of up to $5,500 in reimbursement support across the program.
- Application submission period for this cycle will be open from August 11, 2025 to September 3, 2025 11:59 P.M. EST
I am requesting support for*

MyselfSomeone else
Your Contact Information
Are you the caregiver's employer?*

YesNo
What is your name? *

First NameLast Name
Organization / Company Name:*
Organization / Company Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your phone number?*
Please provide a valid phone number in case we need to contact you about this application.
What is your email address?*
example@example.com
What is your relationship to the person you are requesting assistance for?*
Example: Company Owner, Supervisor, HR Manager, Family Member, etc.
Best time to contact

MorningAfternoonEveningAnytime
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*
Used only for communication regarding this application.
Best time to contact

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 *
Is the caregiver or the employer 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 reimbursement through this program, caregivers 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. Provide proof of caregiving responsibilities and employment status.
5. If applying independently (not through an employer), successfully pass a background check as required by the training provider and applicable laws.
Do you believe the caregiver meets all the above eligibility requirements?*

YesNo
Caregiving Experience

Please answer the following questions about the caregiver's caregiving experience.
Does the caregiver have experience as a caregiver?*

YesNo
Is the caregiver a:*

Professional caregiver (employed by an agency or individual)Family caregiver (providing unpaid care to a friend or relative)Other
Name of caregiver's Employer:*
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
How long has the caregiver been working in a professional caregiving role?*

5+ years3-5 years1-3 years7-12 months0-6 monthsNone
Average number of hours the caregiver provides 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
Does the caregiver currently work with seniors living with dementia?*

NoOccasionallyFrequently
Can the caregiver or their employer pay for this training without Foundation assistance?*

Yes, fullyCan cover part of the costNo, cannot cover the cost
Proof of Caregiving
Attach a copy of the caregiver's latest pay stub or letter of employment from the caregiver's employer on company letterhead.*

If you have any issues uploading documentation, email hello@kristinabutlerfoundation.org
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Situational Questions
What kind of feedback does the caregiver receive on their contributions or achievements in their caregiving role? This could include awards, recognition from colleagues or supervisors, or positive feedback from clients or their families.*

Caregiver receives some positive feedback.Caregiver receives mostly negative feedback.Caregiver has not received feedback but is open to receiving feedback.Caregiver receives consistent positive feedback.
How can the caregiver be counted on to fulfill their caregiving responsibilities?*

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

Caregiver would take responsibility, communicate openly and seek guidance to resolve the situation.Caregiver would acknowledge the mistake and learn from the experience.Caregiver would inform someone about the mistake but might hesitate to take full responsibility.Caergiver would find it difficult to admit mistakes.
Professional Reference Information

Provide contact information for a professional reference who can verify the caregiver's caregiving experience
Reference's Full Name*
Reference's Phone Number*
Please enter a valid phone number.
Caregiver's 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 does the caregiver support?*
What is the caregiver's 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 Dementia Care Certification the caregiver will complete:*
Name of training provider:*
How much will this training cost for this caregiver?*
Please note, entering an amount does not guarantee this amount will be issued. Additional criteria from your application will help us determine the amount you will receive, if eligible.
Anticipated Date of Enrollment (Month / Year)*
Please note, this program will not pay for previously completed training.
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
Why is this caregiver a strong candidate for support?*

0/500
You are welcome to upload any additional documents that should be considered in this 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 Dementia Care Certification Reimbursement 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: