RESPITE CARE APPLICATION – FLORIDA

Caregiving can be a highly demanding and stressful responsibility, and no one is equipped to do it without some help. Just like the loved ones they care for, caregivers also need support and attention to maintain their own health and well-being. Respite care, which provides care partners with the opportunity for a temporary rest from their caregiving duties, is designed to do just that.

How did you hear about Dementia Spotlight Foundation? *
Family Caregiver's Name *
Phone *
Address *
County *
City *
Care Recipient *
Relationship *
Optional Additional Information
Sex
Date of Birth
Monthly Income (approx)
Other Information
Do you have a physician's diagnosis of Dementia/Alzheimer's? *
Please describe your diagnosis.
Are you receiving any other financial assistance? If yes, please specify.
The Dementia Spotlight Foundation provides respite care for loved ones diagnosed with dementia. Providing short-term breaks for caregivers that can relieve their stress, renew their energy and restore a sense of balance to their lives. We’re helping families that financially otherwise cannot afford such services. This is possible though the kindness of those who have donated to our foundation respite care found. Please describe why you need our assistance.
By checking the box below I confirm:
I understand that the role of the Respite Care Program is solely to provide financial assistance for Respite Care and that the Dementia Spotlight Foundation provides neither management nor direction of any Respite Care received by me or by any member of my family. Accordingly, I release and indemnify the Dementia Spotlight Foundation, Inc., its officers and directors from any and all responsibility or liability for any care provided. I understand the information included may be released to agencies/organizations providing funding for seniors to enable the best possible care. * I understand the packet must be utilized within 60 days from date of issue. Caregiver providers must invoice DSF within 30 days of service provided.
Date
How did you hear about Dementia Spotlight Foundation? *
Family Caregiver's Name *
Phone *
Address *
City *
County *
Care Recipient *
Relationship *
Optional Additional Information
Sex
Date of Birth
Monthly Income (approx)
Other Information
Do you have a physician's diagnosis of Dementia/Alzheimer's? *
Please describe your diagnosis.
Are you receiving any other financial assistance? If yes, please specify.
The Dementia Spotlight Foundation provides respite care for loved ones diagnosed with dementia. Providing short-term breaks for caregivers that can relieve their stress, renew their energy and restore a sense of balance to their lives. We’re helping families that financially otherwise cannot afford such services. This is possible though the kindness of those who have donated to our foundation respite care found. Please describe why you need our assistance.
By checking the box below I confirm:
I understand that the role of the Respite Care Program is solely to provide financial assistance for Respite Care and that the Dementia Spotlight Foundation provides neither management nor direction of any Respite Care received by me or by any member of my family. Accordingly, I release and indemnify the Dementia Spotlight Foundation, Inc., its officers and directors from any and all responsibility or liability for any care provided. I understand the information included may be released to agencies/organizations providing funding for seniors to enable the best possible care. * I understand the packet must be utilized within 60 days from date of issue. Caregiver providers must invoice DSF within 30 days of service provided.
Date

A copy of the official registration and financial information may be obtained from the division of consumer services by calling toll-free (800-435-7352) within the state. Registration does not imply endorsement, approval, or recommendation by the state.