Supplemental Respite Grant Program (SRGP) Eligibility Criteria Form (ECF)

First Name

Last Name

Email *

Phone *

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Address

Street Address

City

State

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The SRGP supports primary caregivers who cannot be served by other caregiver support programs or Long-Term Support Waiver Programs by providing $250 per grant request for supplemental respite services.

Are you the primary family caregiver? (you do not need to live with the care recipient) *

I am the primary family caregiver

I am NOT the primary family caregiver.

Does the care recipient live in Wisconsin? *

Yes

Are you receiving respite care funding from any other source? *

Yes

Is the care recipient an adult (18+) or a child (under 18) with special needs who requires care or supervision to meet the person's basic needs? *

Yes

Has the care recipient tried or applied for another support first, is in the process of applying, been denied enrollment, or doesn't qualify for any other caregiver support programs or LTC support programs? *

Yes

Select Funding Source *

Please read before signing the SRGP Eligibility Criteria Form

I have read and understand the Supplemental Respite Grant Program: Overview, Policy, and Procedure by visiting https://respitecarewi.org/wp-content/uploads/2025/02/SRGP-OPP-02.2025.pdf.
I have read and understand the GRANT PROGRAM DETAILED FRAUD DISCLAIMER by visiting https://respitecarewi.org/wp-content/uploads/2023/05/Grant-Program-Detailed-Fraud-Disclaimer.pdf.
I understand that RCAW funds most of its programs with state and federal funds. RCAW is responsible for ensuring funds are used for their intended purpose and in a way that meets the grant's goals and objectives. RCAW reserves the right to deny a grant application if it suspects or detects fraudulent information contained in a grant application. RCAW also reserves the right to report suspected or detected fraud to the appropriate officials, and applicants will be banned from applying for grants in the future. Those involved in fraudulent activities may be subject to repayment of said grant funds to RCAW. All parties involved in grant fraud can potentially be charged with government grant fraud. Using state and federal grant dollars for unjust enrichment, personal gain, or other than their intended use is a form of theft and is subject to criminal prosecution.
I have read and understand the INELIGIBILITY FROM RCAW GRANT PROGRAMS POLICY AND PROCEDURE by visiting https://respitecarewi.org/wp-content/uploads/2024/08/INELIGIBILITY-FROM-RCAW-GRANT-PROGRAMS-POLICY-AND-PROCEDURE.pdf
RCAW reserves the right to deny grant requests at any step of the process at our discretion, with or without cause.
RCAW reserves the right to deny SRGP applications or award a lesser amount, and applicants can appeal using the Grant Denial Appeal Form. If the RCAW Executive Committee denies an applicant’s appeal, the applicant must wait 90 days before reapplying for the SRGP.
I understand the Grant Report: Applicants are expected to track expenses via the SRGP Grant Report. Each quarter, RCAW will select applicants to audit at random. Applicants must keep receipts and invoices for services rendered and purchases made with SRGP funds. If an applicant is chosen for a random audit and cannot provide a completed SRGP Grant report with receipts or invoices, they will immediately be ineligible for future funds and may have to repay RCAW for the SRGP grant funds. If applicants use SRGP funds for a service not listed on the Allowable Expenses, they will immediately be ineligible for future funds and may have to repay RCAW for the SRGP grant funds.
I understand the Allowable Expenses: 1. Qualified home modifications (does not include construction, painting, remodeling, or wear-and-tear upgrades) such as wheelchair ramps, grab bars, Interior and exterior accessible intervention, 2. Assistive technology, emergency response systems, and home safety interventions (does not include new televisions, new washers/dryers, etc.), 3. Home-delivered meals or in-home meal preparation, 4. Technology to decrease isolation and increase social engagement: • For example, tablets/computers to communicate with friends, family, etc. 5. Housekeeping and laundry services, 6. Lawn mowing, 7. Snow removal, 8. Transportation to meaningful or respite activities or medical appointments. 9. Sensory items.
No funding request will be approved to pay for respite incurred before award notification/retroactive services.
Respite Care Association of Wisconsin is not the service provider's employer.
There is no age requirement for the care recipient. This program is available across the lifespan.
You may be eligible to apply for funding several times per year. Please reference the grant’s webpage for up-to-date reapplication information. Funding requests will be subject to the availability of funds.
Primary caregivers or care recipients are responsible for selecting, scheduling, supervising, and reviewing the credentials, background checks, and training of the respite care worker or provider agency chosen .
Applications are on a first-come, first-served basis.
By signing below, I agree to the best of my understanding that all eligibility requirements are accurate, and I understand the above terms.

How did you hear about the SRGP? *

Caregiver County of Residence *

Applicant E-Signature *

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