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
Olivette Strictland (678)408-1049 - Care with a purpose

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!

Why are you applying?

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Applicant's First Name

Applicant's Last Name

Cell number

Additional Phone

Street Address

Include Apartment or Unit Number

City

Zipcode

County

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Are you served by Cobb EMC?

This question is for grant reporting purposes

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

Do you already have a caregiver?

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Other Funding

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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?

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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?

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?

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

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No names or other personal information would be included

List medications

Diagnosis/Challenges

Please list here your child's diagnosis, if they have one, and also any challenges they might have that require special respite care.

List any allergies

Seizures?

If Yes, how do seizures present?

Is your child toilet trained?

How does your child communicate best?

What does your child like to do for fun?

List any feeding Issues

List any behavior Issues