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.

Caregiver's Information (You)

Name *

First

Last

Date of Birth *

Address Line 1 *

Address Line 2

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City *

Province *

Postal Code *

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Phone *

Email *

Do you wish to identify as an Indigenous person?

Are you a Military Family?

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Full Name of person receiving full-time live-in care *

Date of Birth

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Eligibility Criteria

I declare that: *

I provide live-in care on a full-time basis
I am the parent or legal guardian of a person diagnosed with an intellectual disability
I reside 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

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

Please indicate if you have any potential barriers that would impede your ability to accept a Respitality Experience

Transportation
Securing care for my loved one while accessing Respitality
Other

Considerations for Caregiver(s)

Please list any special considerations needed for planning your Respitality Experience

Accessibility / Mobility (if any)

Allergies for Respitality Participants (if any)

How Did You Hear About Respitality? *

Consent

I certify the information I provided in this application for Respitality is true and correct to the best of my knowledge. I hereby authorize the collection, use, and disclosure of my personal information for the purpose of assessing eligibility and program planning for Empower Simcoe’s Respitality program.

Signature *

Please sign with your mouse or touchscreen.