You will need to submit these two documents in addition to this application as well as a 1-page supplement that describes, in your own words, your situation & needs. Please submit all materials to (the application below will automatically come to us via email). 

Name *
Address *
Phone *
Primary Number
Emergency Contact Information
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Other Information
Do you have your own health coverage? *
Family Doctor or other medical personnel who can attest to your need
Family Doctor or other medical personnel who can attest to your need
Their Phone
Their Phone
Will you grant CAREGIFTED all rights to photos/films/sound files of your CAREGIFTED experiences, generated or solicited by us in connection with your award of a getaway? We use such materials to explain the need for caregiver relief programs and to help support the efforts of CAREGIFTED's programs to bring relief to caregivers. *
Can you climb a flight of stairs? (most getaway suites are on the second floor)
Are you able to find care for your child or family member during a CAREGIFTED getaway?
CAREGIFTED Getaways are meant to provide respite to you, the caregiver Unfortunately, at this time, we are unable to provide funding to cover the costs of care in your stead.
Please submit a supplementary sheet to that tells us, in your own words, about your situation and needs. We want to hear your story. Anything you think may be helpful in our selection is welcomed and appreciated.