Respitality Application
 

Respitality is a caregiver-focused program supported entirely by generous community donations and grants.  The responses you provide on your application assist us to target specific donors by region or desired experience type. 

Due to limited resources, eligible caregivers will be entered into a lottery system to receive Respitality. While we aim to support all applicants, availability is not guaranteed.

Caregiver's Information (You)

Name
Preferred Method of Contact:
Do you wish to identify as an Indigenous person?
Are you a Military Family?

Eligibility Criteria

I declare that:
Age of Person Receiving Care
Please indicate which document(s) you will be providing if selected for Respitality:
Please select the region(s) you would prefer to enjoy your Respitality Experience (you may choose more than 1)

Type of Respitality Experience

Please rank the following options from 1 (highest) to 7 (lowest)
Selected Value: 1
Selected Value: 1
Selected Value: 1
Selected Value: 1
Selected Value: 1
Selected Value: 1
Selected Value: 1
Please indicate if you have any potential barriers that would impede your ability to accept a Respitality Experience
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.
Clear Signature
Please sign with your mouse or touchscreen.