CAREGIVERS Welcome to the Independent Living Resource Center of Calgary’s Respite Program. Thank you for taking the time to fill out this application in getting you one step closer in matching with the perfect respite worker for your family. If you have any questions, comments, concerns, or need help filling out the application please contact the ILRCC. *** Please note that all the information gathered in this questionnaire is kept secured. *** General Applicant Information Name(Required) First Last Preferred Name(Required)Email(Required) Cell Phone(Required)Relationship to Client(Required)Best way to contact you: (Check all the apply) Text Phone Email Reason for needing Respite Care(Required)General Information about the person who needs the careName(Required) First Last Preferred name(Required)Email (if different from above) Cell Phone (if different from above)Type of Disability: (Check all the apply)(Required) ADHD Autism Spectrum Disorder Blind Cerebral Palsy Deaf Deafblind Down Syndrome Dyscalculia Dysgraphia Dyslexia Epilepsy Hard of Hearing Intellectual Disability Invisible Disability Learning disabilities Mental Disorder Multiple Disabilities Multiple Sclerosis Muscular Dystrophy Neurological Disorder Physical Disability Spinal Cord Injury Traumatic Brain Injury Vision impairment Other Other DisabilityPreferences1. What languages are spoken at home?(Required)2. For matching purposes and if important to you, please feel free to share your religion with us:(Required)3. Are you looking for a specific gender for your Respite Worker?(Required) Male Female No Preference 4. Is your loved one (check all that apply)(Required) Independent Semi-independent Dependent Aggressive behaviours Complex needs Other Other Needs5. Is there anything more that we should know about your loved one?(Required)What are you searching for? (Check all that apply)(Required) Full time worker Part time worker Casual worker Complex needs worker What days of the week are you needing care for? Check all that apply Monday AM PM Overnight Tuesday AM PM Overnight Wednesday AM PM Overnight Thursday AM PM Overnight Friday AM PM Overnight Saturday AM PM Overnight Sunday AM PM Overnight Other TimesAre you looking for: (Check all that apply)(Required) Live in respite worker (respite worker lives in family home) Live out respite worker (respite worker works in the family home) Out of home respite worker (respite worker supports are typically over a weekend in the family home) In home respite worker (respite worker supports are typically over a weekend in the respite worker's home)
