RISE Application for Families

Thank you for applying

We are excited that you are interested in the RISE program! Please be aware that it may take time to arrange a match, and that a match may not be possible if we do not have students living near to your location. We will do our absolute best! After we receive your application, we will call you for more information and to answer your questions.

For questions, email rise@hov.org.

PRIMARY CAREGIVER LEGAL NAME:

PRIMARY CAREGIVER PHONE:

PRIMARY CAREGIVER EMAIL:

FULL NAME, IF NOT PRIMARY CAREGIVER:

EMAIL, IF NOT PRIMARY CAREGIVER:

ARE YOU CURRENTLY ON THE SUPPORTIVE CARE FOR DEMENTIA PROGRAM?

ADDRESS WHERE VISITS WILL TAKE PLACE?

CITY:

ZIP:

IS THIS A PRIVATE HOME, APARTMENT OR FACILITY?

IF A MATCH WITHIN 12 MILES ISN'T AVAILABLE, WILL YOU COVER MILEAGE REIMBURSEMENT AT $0.75 PER MILE FOR ONE-WAY TRAVEL BEYOND 12 MILES?

PATIENT INTEREST?

GOALS FOR RESPITE CARE?

HOW DID YOU HEAR ABOUT THIS OPPORTUNITY?

WHAT DAYS OF THE WEEK AND TIMES WOULD YOU LIKE A RISE STUDENT VISIT?

COMMENTS?

CONSENT FOR STORING SUBMITTED DATA

Yes, I give permission to store and process my data