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info@cohenspurpose.org
1061 Treasure Lake • DuBois, PA 15801
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Respite Application
Respite Application Form
Caregiver Respite Application Form
Please complete and submit the form below to apply for caregiver respite from Cohen's Purpose.
First Name
*
Spouse Name
Last Name
*
Email address
*
Phone
*
Address
*
City
*
State
*
PA
NY
OH
ZIP
*
Please choose the option that best describes your household.
*
Single Parent
Married
Foster/Adoptive
How did you hear about Cohen's Purpose?
Name of Special Needs Child 1
*
Age
*
Name of Special Needs Child 2
Not Required
Age
Not Required
Name of Special Needs Child 3
Not Required - Contact us if more than 3 special needs children.
Age
Not Required
Does your child have a waiver or ISP?
*
Yes
No
If Yes, through what agency?
If no, do they have an IEP or 504 plan?
Yes
No
Child's primary medical diagnosis:
*
Autism
Cerebral Palsy
Down's Syndrome
Global Development Delay
Life Threatening Illness
Traumatic Brain Injury
Mental Health / Trauma
Rare Syndrome
Other
Describe your child(ren) and the level of care you provide.
*
My child is non-verbal.
I help my child(ren) with all daily living skills (dressing, toileting, bathing, feeding, etc.).
My child(ren) requires a wheelchair for mobility.
My child has social/emotional/behavioral needs daily and requires a behavior plan at school.
My child has a life-threatening illness and is currently receiving treatments for his/her condition.
None of these options apply to my child(ren).
Please select all supports you have for your child.
*
I have family that can take care of my child.
I have friends that can take care of my child.
I have home health nursing services for my child.
I do not have any support system.
My child receives at school/in the community:
*
My child receives related services such as (Physical Therapy, Occupational Therapy, Speech Therapy, Vision Services).
My child is in a specialized classroom (autism support, emotional support, MDS)
My child has a 1:1 aid or nurse at school.
My child has a behavior plan at school.
My child is no longer in school and receives community rehabilitation support.
N/A - My child has a life-threatening illness and is currently receiving treatment.
Any additional info we should know?
Dietary or Mobility Accommodations?
*
What is your biggest challenge as a caregiver to a special needs child?
*
How do you think Cohen’s Purpose will benefit you?
*
What annual retreat are you interested in ?
*
Weekend Respite
“Health and Wellness Day” (for those who can’t get away for a weekend)
Please read and agree to the following statements below:
*
I allow Cohen’s Purpose to use written comments and testimonies I provide to promote Cohen’s Purpose to supporters and other services. Comments and testimonies may Include but not limited to Facebook, Cohen's Purpose website, and advertisement purposes.
I agree to allow Cohen’s Purpose to use photos taken of our weekend retreat or community events.
I authorize the release of my completed application to Cohen’s Purpose. By submitting this application, it does NOT guarantee approval.
I hereby certify that the above statements are true and correct to the best of my knowledge and will be reviewed by the Board to determine approval. I understand that a false statement may affect my abilities to receive services from Cohen’s Purpose.
This application is voluntary and is not a contract. Any personal or medical information will be used for the sole purpose of determining whether applicant qualifies for retreat. All information will be held confidential. The applicant further agrees that if any additional information is needed for approval, it shall be provided at the request to the Board. Applicant agrees to indemnify Cohen's Purpose and its Board of Directors, volunteers, and helpers of any liability from this application and associated partnerships.
Please contact us at
info@cohenspurpose.org
for further assistance.
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Home
About
About Cohen's Purpose
Mission - Vision - Values
Frequently Asked Questions (FAQ)
Our Supporters
Privacy Policy
Testimonials
What We Do
Caregiver Retreats
Community Resources
Spiritual Support
Prayer Request
How to Help
How to Help Cohen's Purpose
Donate
Respite Application
News/Events
Contact
Post-Retreat Survey
Contact Form