David's Refuge Application New

Primary Contact First Name

Primary Contact Last Name

E-mail (David's Refuge does the majority of our communication via email. Please provide a valid email address for communication. If you are unable to do this, please contact the David's Refuge office at 315.682.4204 before completing this application)

Phone

Secondary Contact First Name

Secondary Contact Last Name

Secondary Contact Phone

Secondary Contact E-mail

City

State

Zip Code

County

Name of child with special needs or life-threatening illness

Age of child with special needs or life-threatening illness

Name of 2nd child with special needs or life-threatening illness

Age of 2nd child with special needs or life-threatening illness

Name of 3rd child with special needs or life-threatening illness

Age of 3rd child with special needs or life-threatening illness

Number of neurotypical children living in home

0123 or more

Names and ages of neurotypical children living in your home (Please type none or n/a if this does not apply you).

My child is OPWDD eligible

Yes, I have current documentationNo, my child has a life-threatening illnessNo, my child's disability began after age 22Unsure (Please contact me)

If Other, please describe in detail

If other, please describe in detail

Please select all options that describe your child(ren) and the level of care you provide.

My child is non-verbal or uses an assistive technology device to communicate (tablet/pictures)I have to aid my child(ren) will all daily living skills (dressing, toileting, bathing, feeding, etc)My child(ren) is non ambulatory/requires a wheelchair for all mobility/is unable to walk on their ownMy child has been in the hospital at least once in the last 12 monthsMy child is up at least once every nightMy child has social/emotional/behavioral needs that require daily assistance at home and accommodations or a behavior plan at schoolMy child has a life threatening illness and is currently receiving treatments for his/her conditionNone of these options apply to my child(ren)

Please select all options that apply to the supports your child receives at school/in the community

My child attends the extended school year during the summer to receive supports all year longMy child receives related services (Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy, etc) 3 or more days each weekMy child is in a specialized classroom (12:1:1, 8:1:1, Smaller Classroom, etc)My child has a 1:1 aid at school My child has a behavior plan at school to help manage his/her behaviors during the dayMy child is no longer in school and receives supports in the community (day hab, mentor, etc.) N/A - My child has a life threatening illness and is currently receiving treatment for his/her condition

Please select all supports you have for you and your child

I have family/friends that can take care of my child for a few hours or overnightI have local organizations that help support me/my family (i.e. Gigi's Playhouse, Arise, etc.)I have friends that help support me/my familyThere are organizations in my area that allow my child(ren) to participate in different activities Our family does not have any of these supports

Please share any additional details you feel will give us a better picture of your child(ren) and the level of care you provide each day?

Please choose the programs and services you are interested in participating in.

Weekend RespiteWellness Programs/Retreats (In Person - Central NY and Western NY)Community Events (In Person - Central NY and Western NY)Mental Health Counseling (Individual or couples, this option is virtual)Caregiver Support Group (virtual)Volunteer for David's Refuge

Please choose your option below for Weekend Respite

· Tried and True David's Refuge Respite Weekend - This weekend is a two-night stay at a B&B or hotel. You will choose from a calendar of available dates/locations. During the weekend you will have time with other caregivers (at breakfast each morning) and also time on your own. For this weekend, David's Refuge covers the cost of the location for the weekend and a $100 meal/activity stipend. This style of weekend is available for Caregiving Couples and for Single Parents.

· Reimbursement Respite. (Alternative Option)- This alternative option is available to those caregivers who are NOT ABLE to go on a Tried-and-True Respite Weekend. You MUST BE APPROVED by Respite Manager, Lizconklin@davidsrefuge.org, and meet eligibility requirements. You will receive a secondary form to gather more information. Funding for Reimbursement Respite is limited.

Single Parent - Tried and True David's Refuge Weekend (you choose from dates/locations that we have scheduled)

Caregiving Couple - Tried and True David's Refuge Weekend (you choose from dates/locations that we have scheduled)

Reimbursement Respite - I believe I meet the eligibility requirements for this option, and I understand that I must be approved prior to making arrangements. I will complete the secondary form sent by the Respite Manager.

In your experiences, what do you find to be the most challenging part of being a caregiver to a child with special needs or a life threatening illness?

I allow David's Refuge to use written comments or endorsements I provide to promote David's Refuge to supporters and other families considering services (most times quotes are used anonymously unless we gain permission to include names)

YesNo

I agree to allow David's Refuge to use photos of me or my family when we participate in weekend respite or events with the organization (please note you can make changes to this at any time)

YesNo

Before submitting your application you must read and agree to the three statements below. These boxes must be checked in order for an application to be processed.

I authorize the release of my completed application as needed to gain application approval through the David’s Refuge eligibility teamI hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may affect my abilities to receive services through David's Refuge. I understand that David's Refuge invests on average $600 per family each year. Prior to signing up for any David's Refuge service (including respite weekends, events, mental health supports, workshops, etc.) I will do my best to ensure I have made all arrangements in order to attend.