Step 1

Complete by Patient (Parent/Guardian)

Please begin by completing all forms listed to the right. You will be asked to provide some information about the patient and the individuals who will be attending the respite. We will ask for some details surrounding your preferences for the respite, including time and destination. We will also ask about the situation surrounding the patient's illness, and why a respite is needed. See the table at the bottom of this page for the list of documents you must provide.

Item Required
Insurance Information All Participants
Driver's License / State ID Number All Partipants 18+
Copies of Last Two Pay Stubs Opportunity Cost Only
Copies of Last Three Months of Bank Statements Opportunity Cost Only
Copies of W-2s of Any Working Non-Dependent Family Members Opportunity Cost Only