Respite Care Application (pdf)

Application For Respite Care Program
(Please Print or Type)
PARENT/FAMILY MEMBERS NAME:________________________________________
ADDRESS:____________________________________CITY:____________________
ZIP CODE:__________HOME PHONE:____________WORK PHONE:_____________
Name of Child or Adult Needing Care DIAGNOSIS
OR Adoption Status SOURCE DOB IFSP/IEP
Y/N R S
The child or adult’s diagnosis and source of diagnosis must be listed above. Documentation of the child or adult’s
diagnosis or adoption must accompany this application form. A copy of any document containing the diagnosis and
name of the physician or therapist issuing the diagnosis is sufficient for children or adults with a developmental disability,
and children with developmental delays or chronic medical conditions. If the child has a serious emotional disturbance or
the adult has a severe and persistent mental illness, a summary evaluation form available from the Department of Human
Services (1-800-265-9684) should also be completed by the therapist and returned with the application.
Family member’s relationship to child or adult needing care:
_____________________________________________________________________________.
Are any of the children in your family adopted?_____________(yes or no).
Does your child or adult family member reside in your home the majority of the year?____(yes or no)
If no, please explain:__________________________________________________________________.
Briefly describes how your child's or adult family member's needs affect him/her and your family on a daily basis:
A qualifying family may receive services up to $550 for one eligible child or adult per year, and $200 for each additional
eligible child or adult, up to a maximum of $950 per year, per family. What amount of respite care do you request for your
family for this year? ______________________
I understand that for a child or adult to be eligible for the Respite Care Program they must have a developmental delay
(children under age 5 only) or disability, a serious emotional disturbance, a severe or persistent mental illness, a chronic
medical condition (children only), traumatic brain injury or be adopted; and must reside within the a family members’ home.
I hereby attest that my child(ren) or adult family member meets the eligibility requirements of eligibility for the Respite Care
Program.
SIGNATURE________________________________________________DATE______________
Submit the complete application form with documentation of diagnosis to:
Respite Care Program
Department to Human Services/Division of Developmental Disabilities
E. Hwy. 34; Hillsview Plaza
c/o 500 E. Capitol
Pierre, SD 57501
FOR ASSISTANCE PLEASE CALL 1-800-265-9684