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Lifespan Respite Washington logo featuring a tree with green leaves

Caregiver Application for Respite Voucher

Thank you for your interest in receiving respite voucher through Lifespan Respite Washington.
 
To best work with you, please fill out as much of the form below as you are able to. All questions that have asterisks (*) are required. All other questions help us determine eligibility and need of all applicants. 

If you have any questions, please email getrespite@wapave.org.   
Caregiver Information


















Eligibility and Need












Information about the person receiving care


(MM/DD/YYYY)

For the person receiving care











Authorized Representative Information







Maximum file size is 50MB
Acknowledgement/Agreement
  1. I have reviewed the eligibility on the Lifespan Respite Washington website also available at this link: https://www.lifespanrespitewa.org/voucher-program/ to understand how the Lifespan Respite voucher applies to my situation. I attest that all the information on this application is true and accurate. 
  2. If, during the application process, my care-giving situation changes (e.g., I am no longer providing 40+ hours per week or I receive respite elsewhere), I understand my voucher may be given to another eligible family caregiver. 
  3. I understand I am responsible for selecting a respite provider. The respite provider I select will bill PAVE and PAVE will directly pay the provider. 
  4. I understand that my respite provider may not provide transportation to me/I cannot ride in their vehicle unless the agency as a part of its work provides transportation (e.g. camp, Adult Day Health facility, educational or recreational organization, etc.) and they have provided their insurance certificate to PAVE.
  5. I authorize the exchange of information, including from this application, via common methods (phone, in person, postal mail, fax, email, data entry) among all relevant parties, including formal respite programs to verify, coordinate, and deliver services on behalf of my care receiver and myself.

Indemnification. By selecting the respite provider of his/her own free will, the unpaid, un-served caregiver shall indemnify, defend, and hold harmless PAVE and Lifespan Respite Washington, the State of Washington, the United States Government and the Respite Provider Agency from and against any and all claims, demands, suits, liabilities, and judgments, including attorney’s fees and claims for bodily injury or death, arising from services rendered or for facilities provided with the operation of the LRW Voucher Program.


If you have additional questions and/or will be sending us further documents, contact getrespite@wapave.org.
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