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Jack Norton Family Respite Program Application

 

Live-In Family Caregiver Information

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Person Living with ALS Information

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Question - Required - Gender:


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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Does the person with ALS use any of the following (check all that apply):

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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Does the person with ALS want assistance with the following activities?

 

I hereby authorize The ALS Association, MN/ND/SD Chapter to release the above information to the contracted home care agency designated to provide services (up to 18 hrs/month) to my family. I understand that fees are negotiated on my behalf, and that billing will be sent to The ALS Association, MN/ND/SD Chapter. The ALS Association, and its employees, directors, contractors and agents are released from any and all claims, asserted liability, or actual liability related to or associated with respite care funded by The ALS Association for my family, including, without limitation, any caregiver training provided by The ALS Association and all determinations of need or other determinations of qualification for the Jack Norton Family Respite Program. 

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