Lifespan Respite Voucher Application

Before you begin, please inform the caregiver that:

  • Lifespan respite funds are only awarded when other funding sources are not available.
  • If awarded, respite voucher will be valid for a maximum of 90 days.
  • Priority recipients are caregivers who have not had publicly-funded respite within the last 6 months. (View examples of publicly-funded respite services (PDF).)

Please complete all questions before submission. Incomplete applications will not be accepted.

Referring Agency Information
Family Caregiver Information
Care Recipient Information
Amount of care the family caregiver provides
Background Information
Types of Respite Needed
Family Caregiver Certification and Signature
Referring Agency Certification and Signature

All questions must be completed for this application to be successfully submitted. It you want a copy of the completed application, please print prior to submission; High Country AAA will not be able to provide you with a copy. After hitting the submit button, wait an estimated 30 seconds for your application to be fully submitted. You should find an email in the referring agent's email inbox confirming that the application has been received.