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) InformationCare 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*