SHR Respite Application

River Home Care · River USA Inc.

Riverhomecare.com · respite@riverhomecare.com · 732-314-5960

Youth Information

Youth First Name *

Youth Last Name *

Date of Birth

County

Street Address

City

State

ZIP

Diagnosis / Disability

Parent / Guardian Information

Legal Guardian Name *

Point of Contact Name

Phone Number

Email Address *

Caregiver(s)

A Caregiver may be a household member, but not the youth's immediate caregiver (parent/legal guardian). You can add multiple caregivers if more than one person will provide respite.

Caregiver 1

Full Name

Phone Number

Email Address

Street Address

City

State

ZIP

Social Security Number (last 4 only)

Date of Birth

Relationship to Youth

Caregiver is 18 years of age or older

A fingerprint background check is required. This caregiver must obtain fingerprint clearance (at no cost to them) and provide the receipt to our agency.

Fingerprint Processed Receipt (optional) Click to upload receipt
PDF, JPG, PNG, HEIC accepted

Family Input

To help us provide safe, appropriate, and meaningful services, please complete the following:

Rights & Behavior — What should staff know about your child's rights and expected behavior?

Interests — List any activities, hobbies, or interests your child enjoys:

Limitations on Services/Activities — List any restrictions or activities that should not be done:

Mail Check Payment Agreement

Payments are issued via mailed bank-issued check. Checks may take 5–7 business days. River Home Care is not responsible for checks lost due to outdated addresses.

I agree to the mail check payment terms *

Name on Mailing Address *

Mailing Street Address *

City *

State *

ZIP *

Signature for Mail Check Agreement *

Sign here

Parent / Guardian Consent

By consenting below, the Parent or Legal Guardian:

Agrees to all activities the Caregiver(s) will do with the Youth.
Affirms that proof of a recent Tuberculin Skin (TB) test with medical clearance has been obtained.
Attests that each Caregiver has provided a valid TIN or ITIN and that the family's employment of the Caregiver(s) complies with all applicable State and Federal requirements.
Confirms having received, read, and understood the information and policies in the Family Note Document.

I agree to all of the above *

Parent/Guardian Signature *

Sign here

Enjoy your well deserved break! 😊
For any questions, feel free to reach out — we are always ready to listen.