Caregiver Empowerment Grant Application

If you have questions or need assistance completing this form, contact:

Adrienne Cummins

acummins@youraaa.org
804-343-3029

These funds are provided by a grant from the Jenkins Foundation for caregivers to focus on self-care.

Primary Caregiver Information

Name of Primary Caregiver

Street Address

City

State

Zip

County/City of Residence

Primary Phone Number

Primary Email Address

Date of Birth

Race Check all that apply

Asian or Pacific Islander

African American or Black

Indigenous or Native American

White

Other

Please specify below

Other Race

Ethnicity

Hispanic and/or Latino Not Hispanic or Latino

How are you related to the Care Receiver? I am their:

Spouse or Partner

Adult Child

Sibling

Other

Please specify below

Other Relationship

Do you live full-time with the Care Receiver?

Yes No

About how many hours per week do you provide care?

Are you employed outside of your role as a primary caregiver?

Yes No

Are your caregiver responsibilities affecting your health, emotional well-being, or socialization?

Please describe how you are going to prioritize your well-being.

How do you plan to spend this grant money to begin and maintain the self-care journey you described?

Other source:

Care Receiver Information

Name of Care Receiver

Street Address

If different

City

If different

State

If different

Zip

If different

Date of Birth

Race Check all that apply

Asian or Pacific Islander

African American or Black

Indigenous or Native American

White

Other

Please specify below

Other Race

Ethnicity

Hispanic and/or Latino Not Hispanic or Latino

Is the Care Receiver a Veteran?

Yes No

Care Receiver's Primary Care Needs Check all that apply

Personal Care

(eating, bathing, grooming, dressing, toileting)

Mobility

(transferring from bed/chair, moving around inside, moving around outside)

Household

(cleaning, laundry, grocery shopping, paying bills)

Health Needs

(medication reminders/management, scheduling doctor's appointment)

Skilled Medical/Nursing Care

(feeding tubes, injections, catheters, ostomy care, wound care)

Companion Care

(socialization, recreation, general supervision)

Other needs not mentioned above

Primary Medical Diagnosis of Care Receiver

Neurocognitive Disorder Check all that apply

Alzheimer's

Parkinson's

Lewy Body Dementia

Frontotemporal Dementia

Vascular Dementia

Dementia Unspecified

ALS

Other

Please specify below

Other

Neurological Impairment Check all that apply

Stroke

Traumatic Brain Injury

Spinal Cord Injury

Epilepsy/Seizure Disorder

Other

Please specify below

Other

Physical/Mobility Impairment Check all that apply

Multiple Sclerosis

Muscular Dystrophy

Cerebral Palsy

Other

Please specify below

Other

Sensory/Communication Impairment Check all that apply

Blind/Vision Impaired

Deaf/Hard of Hearing

Sensory Processing Disorder

Other

Please specify below

Other

Emotional/Mental/Psych. Impairment Check all that apply

Depression

PTSD

Schizophrenia

Bipolar Disorder

Anxiety

Other

Please specify below

Other

Are you currently receiving respite care services?

Yes No

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