Caregiver Voucher Eligibility Form | Kerr Tar Regional Council of Governments

Caregiver's Name*

Caregiver's Address*

Caregiver's Email

Caregiver's Phone Number*

Caregiver's County of Residence*

Age of Caregiver*

Relationship to Care Recipient*

Care Recipient's Name*

Care Recipient's County of Residence*

Age of Care Recipient*

Number of Caregivers Involved in Care*

How many hours of care do caregivers provide in a week?*

Describe you caregiving situation?*

How did you hear about our services?*

Select all that apply.

If you selected "Other" above, please let us know how you heard about us.

Does care recipient have Medicaid?*

Does care recipient have memory loss or confusion?*

Are you currently receiving financial assistance from any other sources (i.e. VA)?*

If you answered YES to the previous question, please list source(s) below.

Is there additional information you'd like us to know?