Respite Grant Application

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Please tell us about the individual with dementia or Alzheimer's (Applicant):

Applicant's Name *

Applicant's Date of Birth *

YYYY

Address *

Has the individual received a dementia diagnosis? *

Yes

In the past 12 months has the applicant received respite care assistance from any organization? *

Yes

If yes, please the organization.

Please give the name of the person completing the application: *

Relationship to Applicant *

Your Phone Number: *

Your Email Address

Please briefly explain your need for respite care: *

What Agency will you be using with this grant? Please select the Respite Care Provider from our list: *

Starpath Adult Day Services

Life Skills Centers, Inc. Memory Care Services

Comfort Keeper

Council on Aging Personal Care

Senior Helpers

Visiting Angels

Visiting Nurse Assoc. Health Care Services Private Duty Care

Vinculum Care

Required

I have read the information provided herein and understand that the Dementia & Alzheimer’s Association of St. Clair County is not responsible for any negligence on the part of the agency providing services.

Yes

Required

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