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Respite Care Grant Program Application & Survey

Respite care provides the caregiver some time to relax and take care of his or her personal needs and at the same time offers quality care for the person living with Parkinson’s Disease.

American Parkinson’s Disease Association of Wisconsin (APDA-WI) sponsors the Respite Care Grant Program. Approved applicants will be awarded up to $500.00 per year.

Instructions:

  1. Complete Respite Care Grant Program Application & Survey.
  2. Obtain a statement from respite care recipient’s medical doctor or physician’s assistant that confirms a Parkinson’s Disease diagnosis. Send to APDA-WI:
    • a)statement from medical doctor or physician’s assistant confirming Parkinson’s Disease diagnosis
    • b)completed Respite Care Grant Program Application & Survey to APDA-WI
    • If application has been approved, contact the respite care provider of your choice and interview the respite care provider (see Respite Care Vetting Questions on APDA-WI website: www.wichapterapda.org ).
    • Contact APDA-WI once respite care provider has been selected and let APDA-WI staff know respite care provider contact information. APDA-WI will then contact respite care provider and request provider to complete Respite Care Provider Service Agreement. Once Respite Care Provider Service Agreement has been completed and returned to APDA-WI, APDA-WI will then contact person listed as ‘primary contact’ below to confirm status.

We respect your privacy and will never share your personal information with third parties other than those indicated on this form.

Client and Caregiver Information
(“Client” has Parkinson Disease diagnosis)

Client and Caregiver Information


Client Medical Information


Respite Care Grant Program Terms and Conditions

  • Client Consent: I understand and agree that to participate in the Respite Care Grant Program of the American Parkinson Disease Association (APDA) Wisconsin State Chapter.

    I understand that any additional expenses over the approved $500.00 amount will become the Respite Care Grant recipient’s sole responsibility.

    Release of Liability: I understand that the Wisconsin State Chapter APDA assumes no liability or obligation for delivery of Respite Care services or failure of services provided by the respite care provider.

    • A diagnosis of Parkinson’s disease must be confirmed by the client’s physician.
    • The caregiver applying for the Respite Care Grant program must be the person responsible for providing continuous non-professional care.
    • The individual living with Parkinson’s disease may not be receiving any other funded or subsidized respite care services during the time period recipient is receiving respite care funded by the APDA Respite Care Grant program.
    • The individual living with Parkinson’s disease must not reside in an assisted-living facility or nursing home.
    • The respite care approval process may take 7-10 days from receipt of the application, and will be reviewed in the order received.
    • Once approved for the APDA Respite Care Grant program, the care recipient must be willing to adhere to the respite care provider organization’s policies regarding care.
    • Use respite care, funded by APDA Respite Care Grant program dollars, within 12 months of application.
    • Any care received beyond the approved amount will be the responsibility of the client.
  • PRE-RESPITE CARE SURVEY

  • For the purpose of this survey, a caregiver is someone who assists a person with Parkinson’s disease in various tasks such as transportation, meal preparation, and medication management or is concerned about a loved one.


Verification

Please submit this application and survey to the address, fax number or email address below. If you have any questions, please contact us at (608) 229-7628.

APDA Wisconsin P.O. Box 7513 Madison,

WI 53715
Fax:(608) 259-5327
Scan & Email:Parkinson_assn@ssmhc.com
Thank you so much for taking time to complete and return this application and survey.