Caregiver Respite Grant Program

The Arkansas Autism Foundation

 

Application Guidelines

The Arkansas Autism Foundation, with funding from the Arkansas Lifespan Respite Coalition, is excited to offer respite grants to caregivers. Respite is defined as getting a short-term break from caregiving. These grants of $500 per family per year (August 2021 to August 2022) are not only for parents of children with autism, but caregivers of loved ones with any chronic illness. We ask that applicants provide a current doctor-signed verification of the diagnosis and documented need for caregiving services. Also, the caregiver may not be receiving any other payment for providing care for the individual, and the recipient of care may not be receiving home and community-based waiver or other respite services. These respite grants are available to Arkansas caregivers statewide.

It will take up to 15 business days to process this application.If there is an emergency situation for which respite is needed immediately, indicate and describe below. Please fill out all information required, as incomplete applications will be denied.

In addition to filling out the application below, each applicant is required to provide a Physician Certification. A practicing, certified physician or other qualified healthcare provider must verify the patient’s chronic illness or diagnosis, justifying the need for care provider services. The date, diagnosis, and doctor’s signature must be included with this application and must be written on the professional’s stationary or prescription pad.

Please contact us at grants@arkansasautismfoundation.org or (501) 951-0115 if you have any questions.

    Caregiver Respite Grant Program

    Caregiver Information:

    Accept texts?
    YesNo

    Gender
    MaleFemale

    Ethnicity
    Hispanic or LatinoNot Hispanic or Latino

    Marital Status
    WidowedMarriedDivorcedSingleLegally Separated

    Ethnic Race
    WhiteBlack/African AmericanAmerican IndianAsianHispanicOther

    Is total household monthly net income more than:
    $980.83$1,335$1,680

    Care Recipient (Patient) Information:

    Address: Same as caregiver?
    YesNo

    Gender
    MaleFemale

    Ethnicity
    Hispanic or LatinoNot Hispanic or Latino

    Marital Status
    WidowedMarriedDivorcedSingleLegally Separated

    Ethnic Race
    WhiteBlack/African AmericanAmerican IndianAsianHispanicOther

    Physician Certification:

    A practicing, certified physician or other qualified healthcare provider must verify the patient’s chronic illness or diagnosis, justifying the need for care provider services. The date, diagnosis, and doctor’s signature must be included with this application and must be written on the professional’s stationary or prescription pad.

    Emergency Respite Needed
    YesNo

    I have read and completed the above application and to the best of my knowledge, the information I have provided is correct. I understand that:

    - My grant may be canceled if I have made any false or incomplete statements on this application, either about myself or on behalf of the patient.

    - Arkansas Autism Foundation is not liable for any negligent services by a provider of my own choice.

    - I agree to use these funds for the purpose of respite (a short-term break for caregivers).

    Arkansas Autism Foundation Arkansas Autism Foundation
    11610 Pleasant Ridge Road
    Suite 103, #112
    Little Rock, AR 72223

    Arkansas Autism Foundation on Facebook   Arkansas Autism Foundation on Twitter   Arkansas Autism Foundation on Instagram