Respite Application Form

Caregiver Respite Application Form

Please complete and submit the form below to apply for caregiver respite from Cohen's Purpose.

First Name *

Spouse Name

Last Name *

Email address *

Phone *

Address *

City *

State *

ZIP *

Please choose the option that best describes your household. *

How did you hear about Cohen's Purpose?

Name of Special Needs Child 1 *

Age *

Name of Special Needs Child 2

Not Required

Age

Not Required

Name of Special Needs Child 3

Not Required - Contact us if more than 3 special needs children.

Age

Not Required

Does your child have a waiver or ISP? *

Yes

No

If Yes, through what agency?

If no, do they have an IEP or 504 plan?

Yes

No

Child's primary medical diagnosis: *

Describe your child(ren) and the level of care you provide. *

Please select all supports you have for your child. *

My child receives at school/in the community: *

Any additional info we should know?

Dietary or Mobility Accommodations? *

What is your biggest challenge as a caregiver to a special needs child? *

How do you think Cohen’s Purpose will benefit you? *

What annual retreat are you interested in ? *

Please read and agree to the following statements below: *

I allow Cohen’s Purpose to use written comments and testimonies I provide to promote Cohen’s Purpose to supporters and other services. Comments and testimonies may Include but not limited to Facebook, Cohen's Purpose website, and advertisement purposes.

I agree to allow Cohen’s Purpose to use photos taken of our weekend retreat or community events.

I authorize the release of my completed application to Cohen’s Purpose. By submitting this application, it does NOT guarantee approval.

I hereby certify that the above statements are true and correct to the best of my knowledge and will be reviewed by the Board to determine approval. I understand that a false statement may affect my abilities to receive services from Cohen’s Purpose.

This application is voluntary and is not a contract. Any personal or medical information will be used for the sole purpose of determining whether applicant qualifies for retreat. All information will be held confidential. The applicant further agrees that if any additional information is needed for approval, it shall be provided at the request to the Board. Applicant agrees to indemnify Cohen's Purpose and its Board of Directors, volunteers, and helpers of any liability from this application and associated partnerships.

Please contact us at info@cohenspurpose.org for further assistance.

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