Respitality Application is Now Closed

Please note that if you are selected for a Respitality Experience, you will be asked to provide a copy of your family member’s Psychological Assessment/Psycho-educational Assessment indicating a diagnosis of an Intellectual Disability or Global Developmental Delay, if age 5 and under. Unfortunately, if you are not able to provide this information, you will not meet the eligibility requirements to receive the Respitality Experience.

Please complete all sections of the application. One application per household will be considered.

Caregiver's Information (You)

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Preferred Method of Written Communication:

Email
Mail

Do you wish to identify as an Indigenous person?

Military Family?

Eligibility Criteria

You are: *

Providing live in care on a full-time basis
The parent or legal guardian
Residing in Simcoe County

Age of Person Receiving Care *

Preschool (under 5 years of age)
Child (5-17 years of age)
Adult (18+ years of age)

Please indicate which document(s) you will be providing if selected for Respitality: *

Psychological Assessment/Psycho-educational Assessment indicating a diagnosis of an Intellectual Disability
Assessment indicating Global Developmental Delay, if age 5 and under

Dependants

Name

Date of Birth

Type of Respitality Experience

Please rank the following options from 1 (highest) to 7 (lowest)

Attractions

Selected Value: 1

Dining

Selected Value: 1

Leisure

Selected Value: 1

Music / Arts

Selected Value: 1

Overnight Stay

Selected Value: 1

Recreational Experience

Selected Value: 1

Spa / Wellness

Selected Value: 1

Potential Barriers to Using Respitality

Transportation
Securing care for my loved one while accessing Respitality
Other

Considerations for Caregiver(s)

Accessibility / Mobility (if any)

Allergies for Respitality Participants (if any)

How Did You Hear About Respitality? *

Consent

The personal information that is collected is confidential and used for the purpose of providing you with services and support under the Family Relief Program.