Special Needs Respite

New Scholarship Application

By applying for scholarship funds, please understand that Special Needs Respite is not agreeing to provide a caregiver for you. However, we will do our best to work with you to help you find a caregiver.

Some sources for caregivers:

Jane Roberts - Hallmark Home Care

Your Respite

Kimberly Lewis - Skilltime Behavior Management

Together We Care

Also, by submitting this application, you are agreeing to receive email and text messages from Special Needs Respite to inform you of your application submission and progress, as well as make you aware of what we're doing to help parents of special needs children.

By submitting your application, you are also agreeing to use any funds from Special Needs Respite for getting a break for yourself, such as running errands, seeing a movie, evening or time with a spouse, etc. Funds are not to be used for typical "daycare" situations, such as going to work. As a 501c3 charity, we have a stated purpose that we need to be careful to align with so we can continue helping families. Thank you!

Link to Income Table for Community Reinvestment question

Facilitator Name

If you are getting help filling out this form, please enter that person's name here. Otherwise just leave this field blank.

Why are you applying?

Applicant's First Name

Applicant's Last Name

Cell number

Additional Phone

Street Address

Include Apartment or Unit Number

City

Zipcode

County

Are you served by Cobb EMC?

YesNo

This question is for grant reporting purposes

Community Reinvestment Act Information

Check all that apply. This information helps us gather statistics under Georgia’s Families of Children with Special Needs Reinvestment Act program, helping us help more families! For income table, see this link: https://dch.georgia.gov/document/document/2025-federal-poverty-guidelines/download

Child's First Name

Child's Last Name

Child's Age

Child's Nickname

If you call your child something other than their first name

Sibling(s) Names and Ages

Diagnosis/Challenges

Please let us know more about your child's diagnosis or challenges here.

Do you already have a caregiver?

Other Funding

Do you have other funding such as Georgia Community Support Solutions (GCSS), NOW/COMP Waiver, Department of Behavior Health Development Disability (DBHDD)? Check all that might apply.

If you have not yet applied for any waiver, why not?

If you need help applying for a waiver, please register for this session now: https://www.eventbrite.com/e/nowcomp-navigation-workshop-series-beyond-the-approval-tickets-1621426744039

If you do have other funding (or have applied), please list source and how much you receive or any other pertinent information.

Please indicate the amount you would be able to pay per month for care for your child.

Due to limited scholarship resources, we ask that everyone contribute some towards respite care.

Can you describe to us why you need respite care, and why you need help in paying for it?

For example, if you’re in a situation where caring for your child has caused job loss or dipping into savings. Describe your situation so we can understand how we can help you!

Referred to SNR by (if applicable)

If you don't have a special needs trust for your child, would you like a free 30 minute consultation with an attorney who can help you?

Please check the box if you'd like to have your information shared with a professional. There is no obligation.

If you don't have disability insurance that would help you care for your child in case you are unable, would you like to be contacted by an agent who can help you with that?

Please check the box if you'd like to have your information shared with a professional. There is no obligation.

Do you have guardianship of your special needs child? All parents are required to take legal action to show that you are the best placement for your child. Would like to speak to a professional for assistance in how to proceed?

Please check the box if you'd like to have your information shared with a professional. There is no obligation.

Are you willing to allow your image or child's image to be used by Special Needs Respite to help others in similar circumstances?

No names or other personal information would be included