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Dementia Caregiver Respite Grant Form

"*" indicates required fields

Step 1 of 3

33%

Caregiver Information

(unpaid person providing care to patient)

Caregiver First Name*

Caregiver Middle Name*

Caregiver Last Name*

Caregiver Date of Birth*

Caregiver Age*

Caregiver Gender*

Female

Male

Caregiver Physical Home Address*

Caregiver City*

Caregiver State*

Caregiver Zip*

Caregiver County*

Caregiver Mailing Home Address*

Caregiver City*

Caregiver State*

Caregiver Zip*

Caregiver County*

Caregiver Phone*

Caregiver Email*

Caregiver Marital Status*

Married

Divorced

Separated

SIngle

Widowed

Caregiver Race*

White

Black/African American

American Indian

Asian

Hispanic

Other

Caregiver Military Status*

Retired

Active Duty

Veteran

None

Caregiver Ethnicity*

Hispanic or Latino

Not Hispanic or Latino

Caregiver Relationship to the patient*

How many hours of care do you provide daily?*

How did you hear about this grant*

Caregiver Employment Status*

Employed

Unemployed

Caregiver Annual Household Income*

Have you received a respite assistance grant in the past 12 months?*

Yes

No

If so, from where?*

For what kind of respite assistance are you applying*

In Home Care

Temporary Day Care

Short-Term Facility Stay

Are their any individuals, other than you, with whom we may share grant information? Please list in the space below*

Care Recipient (Patient) Information

Care Recipient First Name*

Care Recipient Middle Name*

Care Recipient Last Name*

Care Recipient Date of Birth*

Care Recipient Age*

Care Recipient Physical Home Address*

Care Recipient City*

Care Recipient State*

Care Recipient Zip*

Care Recipient County*

Care Recipient Mailing Home Address*

Care Recipient City*

Care Recipient State*

Care Recipient Zip*

Care Recipient County*

Care Recipient Phone*

Care Recipient Email*

Marital Status of Care Recipient*

Married

Divorced

Separated

Single

Widowed

Race of Care Recipient*

White

Black/African American

American Indian

Asian

Hispanic

Other

Ethnicity of Care Recipient*

Hispanic or Latino

Not Hispanic or Latino

Military Status of Care Recipient*

Active Duty

Retired

Veteran

None

Patient Diagnosis*

Does the patient live alone*

Yes

No

Patient Primary Speaking Language*

Has the patient recieved/currently utilizing and DHS Waiver or State Plan Service Programs?*

For what kind of respite assistance are you applying*

In Home Care

Temporary Day Care

Short-Term Facility Stay

Are there any individuals, other than you, with whom we may share grant information?*

Pre-Funding Survey

Please rate the level of burden paying out-of-pocket for respite care is on your family*

1

2

3

4

5

Please rate the level of ease in applying for this grant*

1

2

3

4

5

Please rate your current stress level*

1

2

3

4

5

Have you received respite prior to applying for this grant?*

Yes

No

Caregiver Signature

Signature of Caregiver*

Date*

Consent*

The doctor's diagnosis letter is mailed or faxed.*

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?

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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