2. Date:
   Date:
4. Name of Child
5. Date of Birth
6. Parent(s)/ Guardian(s) Name
8. Case Managers Name
9. Agency
   -- Select One --Children's Mental Health ServicesRoss ResourcesNorth Homes
10. Phone number
12. Respite Type
    -- Select One --TraditionalNon-Traditional
13. County
    -- Select One --Itasca CountyKoochiching County
14. Provider Type
    -- Select One --Non-Traditional or cummunity Entity- Family, Friend, Neighbor,YMCA, summer camp, ETC...not including school programsSchool Program or SettingTraditional Foster Care
16. Childs Needs and Strengths
18. Explain how respite services address the childs needs: Give a brief description of the traditonl or non-tradtional respite care service requested
20. Services requesting grant money or check, make payable to:
22. Planned or Emergency
    -- Select One --PlannedEmergencyPlanned and Emergency
23. Date Range of Service
24. CASII Rating at the Time of Application
25. GLBTQIA
    -- Select One --YesNo
27. Number of Days Requested Per Month for Planned Respite
28. Number of Days Per Month for Emergency Respite
29. Race
    -- Select One --American Indian and Alaskan NativeAsianNative Hawaiian or Pacific IslanderBlack or African AmericanWhiteOther
30. Ethnicity
    -- Select One --Not of Hispanic OriginPuerto RicanMexicanCubanOther Hispanic Unknown
32. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
34. Case Manager Electronic Signature*
    By electronically signing you acknowledge that you have spoken to your client and have a signed release on file prior to submitting the referral
36. Upload Indemnification, bills, and other doucments needed for non-traditional respite
38. Grant Manager Signature________________________________________Date:________________

    1. Approve
    2. Deny
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

* indicates a required field