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ALR Provider Background Check Stipend Request
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* Indicates required question
Primary Caregiver First & Last Name
*
Your answer
Email address
*
Your answer
Complete mailing address
*
Your answer
Are you currently enrolled with the Alabama Lifespan Respite program?
*
Yes
No (If you are not enrolled with ALR, you are not eligible to apply)
Unsure
Care Recipient First & Last Name:
*
Your answer
Care Recipient Date of Birth
*
MM
/
DD
/
YYYY
By completing this request, I verify that funds will be used to complete a criminal background check for my respite provider.
*
Agree
Disagree
Required
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