Dementia Respite Grant

How to Apply

1. Access the Application Form
- Online application available at seniorsolutionsvt.org
- Form titled: "2026 Dementia Respite Grant Application"

2. Required Information - Section I: Care Recipient Information
- Preferred name and legal name
- Residential and mailing address
- Email and phone number(s)
- Date of birth and age
- Gender and marital status
- Monthly or yearly gross income
- Physician diagnosis information (Alzheimer's Disease or other progressive dementia)
- Information about current services: Choices for Care Medicaid, VA VDP program, Attendant Services Program, Adult Day Program participation

3. Required Information - Section II: Primary Unpaid Caregiver Information
- Preferred name and legal name of caregiver
- Residential and mailing address (if different from care recipient)
- Email and phone numbers (daytime and evening)
- Date of birth and age
- Gender and marital status
- Ethnicity and race
- Relationship to care recipient (wife, husband, significant other, daughter, son, grandchild, sibling, parent, other relative, non-relative)
- Preference for receiving information on support groups and education resources

4. Required Information - Section III: Caregiver Profile and Needs Assessment
- Check all applicable statements from Primary Unpaid Caregiver Profile:
- Provides care weekly or more (daily)
- Assists with Activities of Daily Living (ADLs)
- Employment affected by caregiving
- Quit or lost employment due to caregiving
- Needs education/training for caregiving
- Solely responsible for caregiving
- Needs assistance with own needs
- Also provides care to other individuals
- Has chronic health condition or recent health crisis
- Primary need is stress/burden relief

- Check all applicable reasons for needing respite services
- Check all intended uses of respite funds

5. Signatures and Consent
- Care recipient signature (if available and able to sign)
- Primary caregiver signature (required)
- Both dated
- Consent for Senior Solutions to share information with organizations offering support groups, education programs, and other services

6. Optional Referral Information
- Referring source contact person name and phone number
- Referring source email

7. Submission
- Complete application and submit online through website
- For assistance, contact HelpLine: 802-885-2669