Thank you for applying for an Easterseals respite voucher program.  Please be sure you are completing the correct form. This application is for the Child and Adolescent Caregiver Respite program.  To be eligible for this program, the child or children for whom you provide care:

• must be 17 years of age or younger
• must have a behavioral or mental health issue or developmental disability  as noted by a medical diagnosis, IEP and/or 504 plan
• must not yet be eligible for/receiving respite services through the Division of Developmental Disabilities Services (DDDS)
• must reside in the same home, with you as a primary caregiver

All information in this application is confidential, however, the Child and Adolescent Caregiver Respite program is partially funded through the Division of Prevention and Behaivioral Health Services (PBHS), and therefore, we are required to share information from this application with them.  

Please read through this application carefully. If you have any questions while you complete this form, or prefer to do it over the phone, please call our office at 302-221-2087.  

As you complete the application, please keep in mind the following:

• Only children with a behavioral or mental health issue, developmental disability or learning disability as noted by a medical diagnosis, IEP and/or 504 plan are eliglbe for this grant. Please do not add information about a child who does not meet the criteria.
• Medical documentation will be required for each child before your application can be processed. This can be a copy of an IEP/504 plan, doctor's note, or other medical documentation. 
• Provide as much detail as you can in order for your caregiving situation to be better understood. The more detail provided means that there is a decreased liklihood of follow-up which can delay processing your application. 

In this section, we'll gather some information about the children with special needs for whom you provide care. You'll need to fill out all of the information for each child. Start with the oldest eligible child.

MEDICAL DOCUMENTATION REQUIREMENT 

In order for your application to be processed, please upload medical documentation confirming the child's diagnosis below. If you applied for more than one child, we will need medical documentation submitted for each child. 

If you are unable to upload the documents, you or the medical practitioner can use the following methods:

• Fax them to 302-414-9943
• Email them to  resources@esdel.org
• Mail them to Easterseals Respite Program, 61 Corporate Circle, New Castle, DE 19720
• Call the office at 302-221-2087

Note: if we do not receive medical documentation, your application will not be processed.