Radiant Hope Respite Care Application

Please include all personal information.

We use this information in the event that we cannot reach you. This person should be an emergency contact, or another adult that will be joinging you for your respite stay.

This information is important for us to review so we can confirm your eligibility for our Respite Care Program. It allows us to ensure the program is the right fit and that we are serving families in accordance with our guidelines.

We ask for this information so we can steward our donor-funded resources responsibly and serve families with the greatest need. This helps us distribute support fairly and in alignment with our mission. All information shared is kept confidential and used only to determine eligibility.

The following information will be taken into consideration as we review your application

Applications are reviewed every two weeks. Approved applicants will be contacted directly. If additional information is needed, we will reach out to you at the phone or email address you provided. We also ask that you have your doctor fill out our Doctor's Note. Please note that if we do not receive confirmation from your treating physician, we cannot consider you for our Respite Care Program.

By submitting an application to Radiant Hope’s Respite Care Program, I/we acknowledge and agree that the following terms and conditions apply to all materials submitted by me/us, my/our family, and any representatives. Radiant Hope receives many applications for the Respite Care Program and is not obligated to approve any specific application. Information provided as part of the application process may be shared with Radiant Hope staff, board members, volunteers, partners, or consultants as necessary to evaluate eligibility and administer the program. While Radiant Hope seeks to handle all information with care and integrity, materials submitted cannot be treated as strictly confidential during the review process. Radiant Hope may also seek guidance from appropriate internal or external advisors when reviewing applications and supporting documentation, and information may be shared as needed for evaluation purposes. Additionally, Radiant Hope may use stories, quotes, photographs, or videos that are voluntarily provided for purposes consistent with its mission, including print, digital, and other media communications, always reflecting the heart and integrity of the Respite Care Program. By submitting this application, I/we acknowledge these terms and release Radiant Hope, including its staff, board members, volunteers, and affiliated partners, from any claims arising from the review and use of submitted materials in accordance with these terms.

IN CONSIDERATION for being permitted to enter and use property secured or arranged by Radiant Hope through its Respite Care Program (hereinafter “the Property”) for rest, vacation, or any related purpose, as well as receiving the services of Radiant Hope, the undersigned, on behalf of himself/herself and his/her personal representatives, family members, guests, children, heirs, and next of kin, acknowledges, agrees, and represents that he/she will inspect the Property upon arrival and will continuously thereafter. Continued presence on the Property constitutes acknowledgment that the undersigned finds the Property safe and reasonably suited for its intended use. If at any time the undersigned believes any condition to be unsafe, he/she agrees that all parties will immediately cease use of the area and notify the appropriate contact.THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES, AND COVENANTS NOT TO SUE Radiant Hope, including its board members, officers, directors, employees, volunteers, agents, affiliated partners, and any property owners providing accommodations through the Respite Care Program (collectively referred to as “Releasees”), from any and all liability for loss, damage, injury, illness, or death that may be sustained by the undersigned or guests, whether caused by the negligence of the Releasees or otherwise, while in or upon the Property.THE UNDERSIGNED AGREES TO INDEMNIFY, DEFEND, AND HOLD HARMLESS the Releasees from any loss, liability, damage, or cost incurred due to the undersigned’s or guests’ presence on or use of the Property, whether caused by negligence or otherwise.The undersigned acknowledges that Radiant Hope does not own the Property and may not have inspected it, and makes no warranties or representations regarding the condition of the Property.THE UNDERSIGNED ASSUMES FULL RESPONSIBILITY FOR ANY RISK OF BODILY INJURY, ILLNESS, DEATH, OR PROPERTY DAMAGE arising from use of the Property, whether caused by negligence or otherwise. The undersigned certifies that he/she and guests have adequate insurance coverage for any potential injury, illness, or damage, or agree to bear the costs personally. The undersigned further affirms that he/she/they do not have any medical conditions that would interfere with safe use of the Property, or otherwise assume full responsibility for any risks created by such conditions. The undersigned understands that certain activities may involve inherent risks, including the risk of serious injury or death.This release and indemnification agreement is intended to be as broad and inclusive as permitted by law. If any portion is held invalid, the remaining provisions shall remain in full force and effect. Any dispute arising out of or related to this Agreement shall be governed by the laws of the Commonwealth of Pennsylvania. The undersigned consents to jurisdiction and venue in the state courts located in Lancaster County, Pennsylvania for resolution of any disputes related to this Agreement.No representations, oral or otherwise, express or implied, other than those specifically set forth in this Agreement, have been made by Radiant Hope or the undersigned regarding the subject matter of this Agreement.