ALR Emergency Respite Application FY24

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The purpose of Emergency Respite is to give caregivers temporary relief while attending to their own urgent physical, emotional, and mental health needs.

The completion of this application does not guarantee the awarding of financial assistance from Alabama Lifespan Respite. Please note that while Alabama Lifespan Respite wishes we could help all qualified individuals who seek assistance, regrettably we only have limited funds to meet the needs of qualified caregivers. Therefore, we can only respond to requests based on our available resources.

Email *

Are you currently enrolled for respite reimbursement with Alabama Lifespan Respite? *

Yes

Unsure

Have you applied for and received Emergency Respite reimbursement from ALR in the past 12 months? *

No (Proceed with application)

Yes (Stop: Do not proceed with application. You do not qualify at this time.)

First and Last Name *

Email *

Phone (including Area Code) *

What is the reason for your emergency? *

Illness (physical, mental, or emotional) or injury that renders you unable to provide care

Hospitalization

In-patient surgery that requires an overnight stay

Outpatient surgery

Death of/funeral for a member of your immediate family (spouse, child, parent, sibling)

Other:

Please add any information that would help us to better understand your emergency: *

Amount of care needed? *

Less than 24 hours

24-48 hours

48-72 hours

Up to a week

More than a week

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms