Elmy's New Jersey Respite Services Registration Form

Thank you for your interest in the NJ Respite Program offered by Elmy's Special Services. This program is dedicated to providing high-quality care and support to individuals diagnosed with developmental disabilities, offering a safe and nurturing environment where they can thrive.

Our services are designed to give caregivers and parents the much-needed break they deserve, ensuring that their loved ones are in good hands.

How to Apply

To apply for our Respite Program, please fill out the application form below with all the required information. Completing this form is the first step in connecting your child with the care and support they need.

Requirement to Apply for the Respite Program

Before you begin the application process, please ensure you have your child's Cyber ID Number, which will let us know beforehand if your child is diagnosed with a Developmental Disability (DD), and is DD-eligible.

In order to get your child's Cyber ID Number, please follow the steps below:

Call 877 652 7624
Register with PerformCare
Get the Cyber ID number to confirm Respite eligibility

Financial Support toward the Respite Program

As with all services provided through CSOC, Family Support services are based on available resources in a given fiscal year. The Financial Support toward Respite and Family Support is based on acuity.

In addition, Financial Support may vary by year and by the number of families that apply. CSOC Financial Support toward Respite should be a last resort.

Since CSOC Financial Support is not guaranteed, families/caregivers should consider their financial ability to pay the balance that exceeds the CSOC cap. Families/caregivers are responsible for the cost of the Respite program minus any financial support provided by CSOC.

Q. Who is eligible for CSOC Financial Support toward Respite Services?

The individual is eligible for CSOC Financial Support toward Respite Services if:

The individual is deemed eligible for CSOC developmental disability (DD) services.
The individual is under the age of 21 and will not turn 21 before the end of the camp dates selected for reimbursement.
The individual resides at home with a caregiver.

Individuals are eligible for CSOC Financial Support toward Respite only during the period of time in which they are not eligible to attend an extended school-year program.

How to apply for Financial Support toward Respite Services?

Families can apply for Financial Support either online or through a paper application. To apply for Alternative Recreational Sessions (ARS), please contact PerformCare at 1-877-652-7624 to request ARS for your child.

Things to Remember

Lunch: Families MUST provide lunch or lunch money.
Sun Safety: hats/caps and sunscreen.
Medical Forms: Medical forms must be completed by a physician and include a signature and stamp.
Financial Assistance: Children's System Of Care (CSOC)

Important Facts

Please note, that each individual is only authorized for up to 10 days by NJ Children’s System of Care (CSOC) and can only begin based on the individuals authorization.

Direct Support Professionals: All DSP’s/Elmy’s staff must go through a pre-screening process before they can come into our programs and interact with our individuals. Our screening process includes a background check and a drug test, and orientation training. Please note, without clearance, they will not be able to provide services during our program.

Grouping Requests: Based on need and assessment some individuals may be approved 1 to 1 staffing.

Important Next Steps After Application

For DD-Eligible Individuals:

Call 609 689 5400: Get in touch with our team to discuss your loved one's needs.
Ask for your Care Connector: A dedicated professional will be assigned to help you navigate the care process.
Choose Elmy's Special Services as your Service Provider: Ensure that you specify Elmy’s as your preferred provider to receive specialized services tailored for your loved one.

For Individuals Not Yet Deemed Eligible:

Call 877-652-7624

Contact this number to initiate the eligibility process for your loved one. Our team is here to assist you with the necessary steps to access our services.

We look forward to welcoming you and your loved ones to Elmy’s Special Services. Our team is committed to providing a supportive and caring environment for your family. If you have any questions or need assistance during the application process, please do not hesitate to contact us.

IMPORTANT: It is necessary for you to have your child's Cyber ID number and have achieved eligibility for Developmental Disabilities through PerformCare.

In order to get your child's Cyber ID Number, and be deemed eligible, please follow the steps below:

Call 877 652 7624
Register with PerformCare and achieve DD-eligibility
Get the Cyber ID number to confirm service eligibility

Please ensure you have completed and possess all the required documentation in order to apply for Elmy's Respite services.

Has eligibility for DD-services been achieved through PerformCare?

Child's Cyber ID Number *

Participant Info

Child’s Name *

Date of birth *

Gender

School *

Grade in September 2024 *

Mailing Address

Street *

City/Suburb

State *

Zip/Post Code *

County

Email Address *

Childs Diagnosis *

Describe your childs behaviours *

What Respite Service are you applying for? *

Note for those who choose AHR: Mandatory compliance with Electronic Visit Verification (EVV) requirements.

Parent/Guardian Info

Name of Parent/Guardian registering child *

Work Phone *

Cell Phone *

Email Address *

Name of 2nd Parent/Guardian

Work Phone

Cell Phone

Email Address

Emergency Contact Info

Please list two (2) contacts not already listed on this form if the Parents/Guardians relation cannot be reached.

Name *

Work Phone *

Cell Phone *

Name

Work Phone

Cell Phone

Physician Info

Name *

Work Phone *

Address

Street *

City/Suburb

State *

Zip/Post Code *

Country *

Authorization/Consent

EMERGENCY AUTHORIZATION: I understand that in the event of an emergency affecting my child while participating in a Elmy’s program, a designated employee of the Elmy’s will attempt to contact me and inform me as soon as possible. In the event I cannot be reached, I hereby give permission for my child to be treated or hospitalized by a licensed physician or hospital selected by the Elmy’s Special Services, Inc.

Parent/Guardian’s Name *

Parent/Guardian Signature

Clear

I consent for emergency authorization.

Participant’s Name *

Date *

Permission Form

I hereby grant permission for my child to participate in all activities of Elmy’s NJ Summer Camp.

I hereby grant permission for my child to participate in field trips, under proper supervision of Elmy’s staff, for park activities and field trips. It is my understanding that these trips will be taken over the camp session without further consent from me.

Parent/Guardian’s Name *

Parent/Guardian’s Signature *

Clear

Participant’s Name *

Date *

Authorized Pick-up Form

The following individuals are 16 years old or older and are allowed to pick up my child from the Elmy’s Summer Camp Program. Those authorized to pick up your child will be asked for photo ID for verification.

Individual 1

Name *

Relationship *

Phone Number *

Individual 2 (optional)

Name

Relationship

Phone

I understand that no one else will be allowed to pick up my child unless I notify Elmy’s staff in advance and in writing. This person will also be asked for their photo ID for verification.

Arrival & Sign In Procedures

I understand that my child must be escorted into the building and a parent/guardian must sign the child in at arrival.

Parent/Guardian Signature *

Clear

Date *

Agreement

I, the undersigned, give permission for my child to participate in Summer Camp. I am aware that a completed medical form signed by a physician is required before my child may begin Summer Camp. I understand that enrollment is based on CSOC authorization. Lastly, I fully understand that my child will participate in field trips and activities. I have read, signed, and agreed to the registration requirements.

Parent/Guardian Signature *

Clear

Parent/Guardian Signature Date *

Standard Release Form

From time to time, Elmy’s Special Services, Inc II (the “Elmy’s NJ”) takes pictures or records videos of individuals participating in Elmy’s NJ programs, using its facilities, or attending one of its special events. Additionally, Elmy’s NJ may permit members of the media (the “Media”) to take such pictures or record such videos in order to promote Elmy’s NJ’s charitable mission and for other mission purposes.

The individual person named below is signing this Release for the purposes of allowing the Elmy’s NJ and the Media to use one or more such photographs, video recordings, and/or sound recordings (collectively, “Recordings”) of such person for any purpose consistent with the Elmy’s NJ’s charitable mission, which includes, but is not limited to, the Elmy’s NJ or the Media publishing such Recordings in newspapers, newsletters, flyers, brochures web sites, and other print or electronic publications, on television, or on the radio. By signing this Release, such person acknowledges that he or she has freely consented to be photographed, filmed, or otherwise recorded and has signed this Release of his or her own free will. If the person named below is under age 18, a parent or guardian of such person must sign on such person’s behalf.

1) I agree that I am willing to be photographed, filmed, or otherwise recorded by Elmy’s NJ, its contractors, and the Media, either individually or as part of a group Recording, which may include my image, likeness, and/or voice. I further agree that my name may be used to identify me as a subject of any Recordings featuring my image, likeness, and/or voice.

2) I understand that Elmy’s NJ will own all rights in the Recordings of me that Elmy’s NJ or a Elmy’s NJ contractor takes or records (“Elmy’s NJ Recordings”), and that Elmy’s NJ will have the exclusive right to use, or allow others to use, such Elmy’s NJ Recordings in any medium for any purpose consistent with the Elmy’s NJ’s charitable mission as determined by the Elmy’s NJ.

3) I understand that the Media will own all rights in the Recordings of me that the Media takes or records (“Media Recordings”), and that the Media will have the exclusive right to use, or allow others to use, such Media Recordings in any medium for any lawful purpose.

4) I understand that I am waiving any and all rights that may preclude Elmy’s NJ’s or the Media’s use of the Recordings as described above.

5) I acknowledge that neither the Elmy’s NJ nor the Media has any obligation to use any Recordings of me or to use such Recordings for any particular purpose.

6) I understand that I will receive no monetary payment or other compensation in exchange for the rights to use Recordings of me.

Participant’s Name (printed) *

Name of Parent/Guardian *

Parent/Guardian's Signature *

Clear

Date *