Respite Form

To be Completed by Patient or Parent/Guardian Only

Please make sure all required fields are filled and items such as phone numbers, emails, etc. are correct.

Contact Person Information*

Relationship to the Patient

Patient Information

Patient Name*

Patient Email

Patient Date of Birth*

The following demographic information is being requested for Administrative, Fundraising, and Research purposes only.

Please fill out to the best of your ability. You may choose not to answer.

What is the patient's ethnicity?

What is the patient's race?

What gender does the patient identify as?

Patient Home Address*

Patient county of residence*

Respite Information

Does the patient have health insurance?*

Patient Primary Insurance Company*

Drivers License Information for patient or parent/guardians*

Do any respite attendees have physical limitations or require special accommodations (including personal nursing care)?*

Attendee Physical Limitations

Please select two months of preferred travel times.*

Please indicate the preferred travel year.*

What is your first choice destination?*

What is your second choice destination?*

How many additional people will be attending the respite?

Please provide a detailed description of the patient's current situation and how it has affected the family and care team. Why do you feel a respite through A Week Away should be granted?*

Have the patient or any family members previously participated in a Dream, Wish, or any other similar program within one year of submitting this application? If so, please describe.*

Are you applying for opportunity cost coverage?*

If you have a CaringBridge or Facebook page, please share the link so we can follow your story

Privacy Notice / Policy

Acknowledgments of A Week Away's Privacy Notice / Policy

Set forth below is my/our signed acknowledgment and agreement that the following terms and conditions apply to all materials submitted by me/us and my/our family or agents representatives and agents of A Week Away. Accordingly, the Client acknowledges and agrees with the following terms and conditions governing the application and supporting documentation:

1. A Week Away considers many applications for goods and services and is not under any obligation to accept my application.

2. A Week Away applicants are not assured that the information shared will be maintained as confidential. There is no expectation of confidentiality and it can’t be treated as confidential because A Week Away will need to share various information during the evaluation process with folks like employees, consultants, affiliates, and others. Marking the information as confidential or requesting confidentiality does not change this result.

3. A Week Away often seeks the advice of an appropriate internal or external expert in evaluating applications and supporting documentation and therefore cannot agree not to disclose the information contained in a submission to third parties and/or employees or volunteers within A Week Away.

4. A Week Away may use any information supplied by me for the purposes of its own publicity. A Week Away may edit, use and reuse such information, as well as videos, photographs, quotes or movies for its own purposes including use in print, on the internet and all other forms of media.

By signing below, I am releasing A Week Away (and this includes, for example, folks working for the nonprofit and any other related individuals/entities) from all claims, demands and liabilities. A Week Away will use the application contents, including any supporting documentation, for any purpose.

IN WITNESS WHEREOF, I have so agreed and have set my hand below*

Property Use Agreement & Waiver of Liability

A Week Away Property Use Agreement & Waiver of Liability

IN CONSIDERATION for being permitted to enter premises and property secured by A Week Away, hereinafter “the Property,” for vacation or any other purpose as well as the services of A Week Away, the undersigned for himself/herself, his/her personal representatives, family, extended family, relatives, guests, children, heirs, and next of kin, acknowledges, agrees, and represents that he/she has or will immediately upon entering, and will continuously thereafter, thoroughly inspect such areas and his/her continued presence constitutes an acknowledgment that he/she has inspected the property and he/she finds and accepts such areas as being safe and reasonably suited for the purposes of his/her use, and he/she further agrees and warrants that if at any time, he/she feels anything to be unsafe, he/she and all guests will immediately leave the area and advise appropriate persons.

THE UNDERSIGNED hereby RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE EITHER A Week Away, its members, managers, operators, officials, officers, directors, employees, agents or volunteers or [property owners] personally and as company or corporate representatives, their members, managers, operators, officials, officers, directors, employees, owners, and lessees of the premises, all for the purposes hereinafter as “Releasees,” from all liability to the undersigned, guests, representatives, assigns, heirs and next of kin for any and all loss or damage, and any claim or demand thereof on account of INJURY to the person(s) or property or resulting in DEATH of the undersigned or guests, whether caused by negligence of the Releasees or otherwise while in or upon the area.

THE UNDERSIGNED hereby AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the Releasees and each of them from any loss, liability, damage, or cost they may occur due to their presence in or upon the area and whether caused by the negligence of the Releasees or otherwise.

THE UNDERSIGNED acknowledges and understands that A Week Away has not inspected the Property, does not own the Property, and makes no warranties or representations regarding the Property.

THE UNDERSIGNED hereby ASSUMES FULL RESPONSIBILITY FOR RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to the negligence of the Releasees or otherwise while in or upon the Property. THE UNDERSIGNED hereby certifies that he/she and guests (they) have adequate insurance to cover any injury, illness or damage that may be caused or suffered while in or upon area, or else agrees to bear the costs of such damage or injury. The undersigned further that he/she/they have no medical conditions which would interfere with use of the Property or else assume and bear the costs of all risks that may be created, directly or indirectly, by any such condition and expressly acknowledges such physical activities are dangerous and involve the risk of serious injury and/or death and/or property damage. The undersigned further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by law and that if any provision is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Any dispute, controversy or claim arising out of or related to this Agreement or the interpretation of this Agreement shall be settled under the laws of the State of Pennsylvania. I/we consent to jurisdiction and venue in the state court located in Lancaster County, Pennsylvania for the resolution of any and all disputes regarding this Agreement. If a court of competent jurisdiction shall find any portion of this Agreement invalid, such decision shall have no effect on the remainder of this lease.

No representations, oral or otherwise, express or implied, other than those specifically set forth in this Agreement have been made by Releasees or Undersigned regarding the subject matter of this Agreement.

IN WITNESS WHEREOF, I have so agreed and have set my hand below*

Is there anything additional you'd like to add to this application?

Attendee #rawval Information

Attendee Name*

Date of Birth

Attendee Information