• Caregiver Support Fund Application

    10/1/2026 - 9/1/2027

  • Thank you for applying for Easterseals Caregiver Support Fund. Please read through this application carefully and be sure that you meet the eligibilty requirements. To be eligible for this supplemental respite program, you must meet the following requirements:

    • You are an unpaid family caregiver
    • You and the person receiving care are Delaware residents

    Easterseals Caregiver Support Fund is partially funded through the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) through the National Family Caregiver Support Program, Title III-E of the Older Americans Act, so one of the following requirements also must be met:

    • You are caring for someone 60 years of age or older OR
    • You are caring for someone with Alzheimer's disease or a related disorder OR
    • You are 55 years of age or older

    If you do not meet the eligibility requirements, please complete this form: Caregiver Information Form and one of our Case Managers will follow up with you.

    All others, please continue reading and click next at the bottom of the page to complete the application.

    The Caregiver Support Fund provides funding for non-traditional types of respite which support caregivers at home.  Examples of items that might be covered include grab bars, lawn care, or home delivered meals.  Please click this link to see the list of eligible and inelgible items (XXXXX).  If you have any questions about how you are intending to use the requested funding, please feel free to contact our office at resources@esdel.org or 302-221-2291.  Important:  funds are provided as a cost reimbursement.  Please do not purchase any supports or services until you have completed an application and received written approval from Easterseals.

     

    Please Note: All information in this application is confidential, and shared only with necessary staff and as required by DSAAPD, the funding agency.  Some non-identifying information may be shared with members of the Respite Coaltion as part of this pilot program.

    If you have questions, please contact our office at 302-221-2291 or resources@esdel.org and our staff would be happy to help. 

    Easterseals Privacy Policy can be found at this link:  Easterseals Privacy Policy

  • As you fill out this application, keep the following in mind:

    1. If you are assisting the caregiver with this application, please provide THEIR information, not yours.

    2. "Caregiver" refers to the person providing the majority of the care.

    3. "Care recipient" refers to the person who is receiving care. 

     

    Please only submit one application. Duplicate applications cause delays in processing. You will receive a "Thank you" email from Jotform letting you know that the application was successfully submitted. If you do not see the email, please contact resources@esdel.org and one of our staff will check if the application was received. 

     

     

  • Who is completing this form:*
  • Have you completed an application for Easterseals Moments of Rest grant since October 1, 2026?
  • Have you received a Caregiver Support Fund grant since October 1, 2026?

  • Caregiver Information

    On this page, fill in the information for the person who is providing the majority of the care.
  • What is your date of birth?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What is your gender?*
  • What is your ethnicity?*
  • What is your race?*

  • In which county do you live?*
  •  -
  •  -
  • Please select all that apply:*
  • Is the caregiver, or another family member in the home, in the military or a veteran?*

  • Are you paid to provide care to your loved one?*
  • Are you receiving respite services from any of the following organizations?*

  • How did you hear about the Easterseals Caregiver Support Fund program?*

  • Caregiving Relationship

  • Who do you care for (the care recipient)?*
  • How are you related to the person needing care?*

  • Please note that you may be required to provide additional documentation to prove that you have primary responsibility for the care recipient(s). This may include but is not limited to:

    • School registration documents
    • Medical documentation
    • Medicaid or other benefit documents

    If you have any questions, please contact our office at 302-221-2291 or resources@esdel.org. 

     

  • Care Recipient Information

    On this page, fill in the information for the person who is receiving care.
  • What is the care recipient's date of birth?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What is the care recipient's gender?*
  • What is the care recipient's ethnicity?*
  • What is the care recipient's race?*

  • Is the care recipient a veteran?*
  • Does the person receiving care live with you at your address?*
  • In which county does the care recipient live?*
  • Does the care recipient live alone?
  • What is the PRIMARY diagnosis for the person receiving care?*

  • What will you be using the Caregiver Support Fund grant to purchase:
  • Do you care for another care recipient?*
  • How many other people do you provide care for other than the person listed above?

  • If your loved one has received Easterseals services within the last two years, with your permission, we can contact that program for medical documentation and no other medical documentation is needed. By selecting the program below, you are giving us permission to contact the program. If this does not apply, please move on to next question.

  • MEDICAL DOCUMENTATION REQUIREMENT 

    In order for your application to be processed, please upload current medical documentation (within 6-12 months) confirming each Care Recipient's diagnosis using the link below.

    If you are applying as a non-parent relative, you do not need to send medical documentation, but please email resources@esdel.org and request the necessary form to confirm continued guardianship.

    If you are unable to upload the documents, you or the medical practitioner can use the following methods:

    Fax them to 302-414-9943
    Email them to resources@esdel.org
    Mail them to Easterseals Respite Program, 61 Corporate Circle, New Castle, DE 19720
    Call the office at 302-221-2291
     

    Note: We need medical documentation submitted even if you submitted documentation previously. If we do not receive medical documentation, your application will not be processed.

     

     

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  • New this year:  

    In order for your application to be considered, you must complete the 12-question Zarit Caregiver Burden assessment.  Please click this link to complete the questionnaire:  Zarit Caregiver Burden Assessment

    NOTE:  Be sure to come back to this page to complete and submit the application.

  • Moments of Rest Grant Program Guidelines

    If you are filling out the application on behalf of the caregiver, please read the statements below exactly as they appear.
  • I attest that:*
  • I agree that I CANNOT complete the services myself and the person I hire:*
  • Notices:*
  • I have completed the Zarit Caregiver Burden assessment.*

  • Please click this link to complete the Zarit Caregiver Burden assessment as a requirement of applying for this program:  Zarit Caregiver Burden Assessment

     

    BE SURE TO RETURN TO THIS PAGE TO SUBMIT THE APPLICATION!

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