APPLICATION FOR RESPITE CARE
VIRGINIA M. SCHROEDER FUND

Please fill out the application except for the clergy use only section.  Print it out and ask your selected clergy member to fill out the For Clergy use only section.  When the application is complete, send by fax to (203) 316-8614 or by mail to InterFaith Council of Southwestern Connecticut, One Canterbury Green, Box #7, Stamford, CT 06901.  The information that you provide will be held confidential by the clergy who signs it and the members of the InterFaith Council who process it.

 Individual Receiving Care 
 Date of Birth 

 Street address   
 City, State, Zip  

 Telephone Number

 Caregiver's Name
 (include your relationship)

 Caregiver's Street Address
 City, State, Zip

 Caregiver's Telephone Number

  Caregiver's Email:

 1.  Please provide a brief description of the nature of the care you provide and the reason you are seeking respite care funding. 

 2.  Special needs or requirements of the person needing care.

 3.  Are you in need of financial help to pay for respite care? Yes No

 4.  Have you received funds for respite care in the past?  Yes No
      If so, please explain when and from whom.
 

 5.  Is the person for whom you care also connected to a social service or other agency from which we could obtain further information?  Yes No
If so, which agency    (If you and the person for whom you provide care are not currently connected to a human services agency, we suggest that you explore this possibility.)

 6.  Do we have your permission to contact that agency regarding the cared for person? Yes No

 7.  For what week or more are you requesting respite funding?

 8.  Is this 24-hour coverage?  Yes No
    If not, please explain and tell us how many hours you wish coverage.
 

 9.  If needed, we will arrange for a nurse or social worker to visit with you and the person for whom you provide care concerning this application.  What is a good time for us to call regarding this visit?   

 10.  Name, Address and Phone Number of Agency that you wish to have provide the respite care
    Name                          
    Street Address          
    City, State, Zip           

 11.  Have you contacted them?  Yes No    If not, you will have to contact the agency before any funds can be provided.

By signing this application, you are agreeing to have your name and the name of the person for whom you provide care entered in a database.   This helps us ensure that funds are spread over a large number of people. 

 Signed_____________________________________________________

 Dated_________________________

 For clergy use only:

I have met with______________________________________________ and spoken with him/her regarding the need for respite care.  I have found it appropriate to recommend this grant._________
 or
I would prefer that a parish nurse or social worker confer with this individual concerning the need for respite care and report back to me._______

 Clergy signature___________________________________    Date______________

 Print Name________________________________________________

 Congregation_______________________________________________

Telephone___________________  e-mail address_________________________

(Clergy Members: please return this form to applicant when complete.)

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