Dementia Respite Care Advocates (DRCA) Grant Application

Please fill out the application information below.

If approved, a member of our team will be in contact with you for next steps.

Please note that these grants are reviewed quarterly and funds must be used in the quarter following approval.

Caregiver Information:

First Name

Middle Name

Last Name

Birthday

Mailing Address

Physical Address (if different)

County of Residence

Phone

Why are you requesting respite care assistance?

Care Receiver Information:

First Name

Middle Name

Last Name

Birthday

Physical Address

County of Residence

The care receiver: (check all that apply)

Has special/chronic health needs

Has Alzheimer's disease or other dementia

Has developmental disabilities

Has deficits in two or more activities of daily living (e.g. feeding, toileting, mobility, dressing)

Is enrolled in Medicaid or a Medicaid Waiver Program

Receives Supplemental Security Income (SSI)

The Caregiver applicant recognizes and agrees that the Cody Owens Foundation, the Dementia Respite Care Advocates (DRCA), and all other agencies, entities and/or individuals participating in this respite care program are not providing direct or indirect services of any kind to the Care Receiver identified above; and the Caregiver applicant agrees to and shall hold harmless and indemnify these participating agencies, entities and/or individuals for any and all damages, expenses or liabilities arising out of, or resulting from, the execution of this application. Completion of this application does not guarantee delivery of monies, anything of value, or services.

Thanks for submitting!