Balancing caregivers' emotional and physical needs is an ongoing challenge, and the magnitude of those needs can be great for those affected by ALS. 

Respite Care is a program that refers to short-term, temporary care provided to those needing assistance. The goal of respite is to provide a safe environment for the Person with ALS (pALS) in the primary caregiver's absence. This allows the caregiver of a person with ALS (cALS) time away from direct caregiving responsibilities. Because each situation is unique, ALS in the Heartland has implemented a grant system, enabling the family to utilize respite care to best meet their individual needs. 

By signing below, I certify that all information is accurate and correct to the best of my knowledge.

I authorize ALS in the Heartland to release general information to grant funders, including Team Gleason and the Enrichment Foundation.

I fully understand that ALS in the Heartland will provide payment or reimbursement for respite care pending available funds. I understand I can utilize and pay for as many hours of respite care as needed, and ALS in the Heartland will reimburse up to a certain dollar amount per month. No payment will be made for any respite care service completed prior to the application date and intake session. 

The pALS and their family/cALS will determine the care provider, type of care, number of hours, and frequency of services. It is up to the family to ensure that the pALS receives the appropriate care and may choose to change providers if needed. The provided services will be listed and verified by the professional and monitored by ALS in the Heartland staff.

I fully understand that these funds are provided to assist in short-term, temporary care provided to pALS, and these funds will stop upon the death of the individual diagnosed with ALS.

I have read and fully understand the policy and procedures of ALS in the Heartland's Respite Grant Program.

I have requested participation in the Respite Grant Program offered by ALS in the Heartland. As a condition to being granted permission to participate in the Program, I agree to release, indemnify, and hold harmless ALS in the Heartland, its principals, officers, successors, assigns, staff, employees, agents, volunteers, funders, and participants from any and all claims, liabilities, losses, and causes of action arising from or related to participation in the Program.

I understand that ALS in the Heartland is responsible for payment to or reimbursement for paid caregivers, professional care individuals, and agencies. I understand that I must ensure that the care provider has the appropriate training to care for the needs of the person receiving care. If the care provider is not appropriately trained, I may choose to provide that training myself or find another care provider. 

By this Waiver, I assume any risk and take full responsibility and waive any claims of personal injury or death, or damage to or loss of personal property associated with participation in the Program, arising out of or caused by the negligence, in whole or in part, of ALS in the Heartland.