2026 Dementia Respite Grant Application

Senior Solutions Dementia Respite Grant Application

Dementia Respite Grant Application – 2026

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Section I: Care Recipient Information

Please provide the following information about the individual with dementia.
Preferred Name of Care Recipient(Required)
Legal Name of Care Recipient (if different)
Care Recipient Residential Address(Required)
Care Recipient Mailing Address (if different than above)
Care Recipient Date of Birth(Required)
Care Recipient Gender(Required)
Care Recipient Marital Status(Required)
Income Information(Required)
Monthly or Yearly Income(Required)
Does the care recipient have a physician's diagnosis of Alzheimer's Disease?(Required)
If no, is there a physician's diagnosis of another progressive, irreversible dementia?
Has the care recipient applied for the Choices for Care Medicaid Program?(Required)
Does the care recipient receive services through Choices for Care?(Required)
Does the care recipient receive services through the VA VDP program?(Required)
Has the care recipient applied for the Attendant Services Program?(Required)
Does the care recipient participate in an Adult Day Program?(Required)
If yes, indicate source of payment

Section II: Primary Unpaid Caregiver (Grant Applicant) Information

Preferred Name of Primary Unpaid Caregiver(Required)
Legal Name of Primary Unpaid Caregiver (if different)
Caregiver Residential Address (if different from care recipient)
Caregiver Mailing Address (communication about the Dementia Respite program will be mailed here))
Do you wish to receive information/education on support groups, websites, etc.)?(Required)
Is it permissible to leave messages at your daytime number?(Required)
Caregiver Gender(Required)
Caregiver Date of Birth(Required)
Caregiver Marital Status(Required)
Ethnicity of Primary Unpaid Caregiver(Required)
Race of Primary Unpaid Caregiver(Required)
Relationship of Primary Unpaid Caregiver to Care Recipient (check one only)(Required)

Section III: Additional Questions

Primary Unpaid Caregiver Profile(Required)
Please Check All That Apply
Reasons for Needing Respite(Required)
Please Check All That Apply
Intended Uses of Respite Funds(Required)
Please Check All That Apply

Section IV: Consent and Release

Consent(Required)
Clear Signature
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Clear Signature
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Referring source contact person