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CareLink Caregiver Support Grant Form

"*" indicates required fields

Step 1 of 2

50%

Caregiver Information

(unpaid family/friend caregiver)

Caregiver Full Name*

First Last

Caregiver Address*

Caregiver City*

Caregiver State*

Caregiver Zip*

Caregiver Phone*

Caregiver Email*

Caregiver DOB*

Caregiver SSN*

Caregiver Gender*

Male

Female

Caregiver Ethnicity*

Hispanic or Latino

Not Hispanic or Latino

Caregiver Marital Status*

Widowed

Married

Divorced

Single

Caregiver Race*

White

Black/African American

American Indian

Asian

Hispanic

Other

Do you live in a rural area?*

Yes

No

Do you live alone?*

Yes

No

Caregiver Relationship to patient*

Hours of care you provide daily*

How did you hear about this grant*

Gross monthly household income*

Care Recipient (Patient) Information

Care Recipient Full Name*

First Last

Care Recipient Physical Address*

Care Recipient City*

Care Recipient State*

Care Recipient Zip*

Care Recipient Phone*

Care Recipient Email*

Care Recipient DOB*

Care Recipient SSN*

Care Recipient Ethnicity*

Hispanic or Latino

Not Hispanic or Latino

Care Recipient Gender*

Male

Female

Care Recipient Marital Status*

Widowed

Married

Divorced

Single

Care Recipient Race*

White

Black/African American

American Indian

Asian

Hispanic

Other

Does the patient live in a rural area?*

Yes

No

Does the patient live alone?*

Yes

No

Diagnosis*

Primary Speaking Language*

County Care Recipient Resides In*

What Kind of Assistance*

In-Home Care

Adult Daycare

Short Term Facility Stay

Does the patient receive respite services from any of the following:*

Select...

Private Health Insurance

Medicare

Medicaid

Hospice

ARChoices

Independent Choices

CareLink

PACE

DHS

Health Department

SSI

VA

Other

Signature of Patient/Patient's Designated Respresentative*

Date*

Acceptance Signature of Caregiver (Unpaid family/friend)*

Date*

Consent*

The doctor's diagnosis letter is mailed or faxed. Provide your signature below.*

Signature of Patient/Patient's Designated Respresentative*

Consent*

I agree and understand that by signing electronically, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. Provide your signature below.*

Signature of Patient/Patient's Designated Respresentative*

Receive Updates

Email*
First Name*
Last Name*
In which Arkansas County do you live?*

By submitting this form, you are consenting to receive marketing emails from: Alzheimer’s Arkansas, 201 Markham Center Drive, Little Rock, AR, 72205, http://www.alzark.org/. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact.

Text to Donate

alzark to 44321

Give Lively is our authorized platform for giving.

Address:

201 Markham Center Drive
Little Rock, AR 72205

Email: [email protected]

Hours: M-F 8:30am – 4:30pm
Phone: 501-224-0021
Fax: 501-227-6303

For immediate caregiver assistance after hours, call our Caregiver Line at 800-689-6090.

EIN: 71-0590114

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