Seniors Raising Children/Older Relative Caregiver Application

Seniors Raising Children/Older Relative Caregiver Application

As a part of the Family Caregiver Support Program, the Seniors Raising Children/Older Relative Caregiver Program assist seniors age 55 or older who are raising children. To qualify for the Seniors Raising Children/Older Relative Caregiver Program, there are several requirements that must be met. The child must be under the age of 18 and live in your home. The child's parent cannot be residing in the home. The senior applying for assistance must provide a South Carolina-issued photo ID that includes their home address. The senior must submit supporting documentation from the court ordered custody or from an educational institution or an approved agency that verifies the home address of the minor(s). All criteria and documentation must be provided in order to receive assistance.

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FISCAL YEAR _______________ # _________________
DO YOU QUALIFY FOR THIS PROGRAM?
To be considered for assistance, you must fulfill all five criteria listed below and submit all necessary documents.
Select all that apply.(Required)
Select all that apply.
1. The child is under the age of 18.
2. The child lives in my home.
3. The parent of the child is not residing in the home.
4. I have a South Carolina photo ID with my home address listed.
5. I can provide supporting documentation (e.g., court order, educational institution, or approved agency) verifying the home address of the minor(s).
CAREGIVER INFORMATION
Client Status:(Required)

New Client

Returning Client
Caregiver Name:(Required)
First Last
Caregiver Address:(Required)
Physical Address Mailing Address (if different from physical address) City State / Province / Region ZIP / Postal Code

Caregiver County:(Required)

Abbeville

Edgefield

Greenwood

Laurens

McCormick

Saluda
Caregiver Primary Phone:(Required)
Caregiver Secondary Phone
Caregiver Age:(Required)
Caregiver Date of Birth:(Required)
MM slash DD slash YYYY

Do you have Internet Access?(Required)

Yes

No
Caregiver Email:

CAREGIVER DEMOGRAPHICS
Caregiver Gender:(Required)

Female

Male

Decline
Caregiver Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Declined
Caregiver Race:(Required)

American Indian/ Alaska Native

Asian/Asian American

Black/African American

Native Hawaiian/Pacific Islander

White

Declined

Other

Caregiver Marital Status:(Required)

Married

Widowed

Divorced

Single

Domestic Partner/Civil Union
Number in Caregiver Household:(Required)
Caregiver Monthly Household Income:(Required)
CAREGIVER QUESTIONNAIRE
Are you currently employed?(Required)

Full-Time

Part-Time

Not Employed

Retired
How would you rate your emotional well-being?(Required)

Excellent

Good

Fair

Poor
Do you feel disconnected from child(ren) or feel it is difficult to communicate with child(ren)?(Required)

Yes

No
Please briefly describe circumstances that lead to your involvement of raising child(ren):(Required)
CHILD #1 INFORMATION
Child #1 Name:(Required)
First Last
Child #1 Date of Birth:(Required)
MM slash DD slash YYYY

Child #1 Age:(Required)
Child #1 Grade:(Required)
(Enter NA if not in school)
Caregiver Relationship to Child #1:(Required)

Grandparent

Other

Child #1 Greatest Need:(Required)
Child #1 Gender:(Required)

Female

Male

Decline
Child #1 Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Declined
Child #1 Race:(Required)

American Indian/ Alaska Native

Asian/Asian American

Black/African American

Native Hawaiian/Pacific Islander

White

Declined

Other

Is child #1 currently receiving services from any of the following:(Required)
(Check all that apply)
Medicaid
Medicare
SNAP
VA
TANF
Child Support from Father
Child Support from Mother
Social Security Benefits
How many years/months have you been caring for child #1?(Required)
Does child #1 have any learning impairments?(Required)

Yes

No
List any learning impairments below:(Required)
Is there anyone else that provides care for child #1?(Required)

Yes

No
List the provider and what type of support they provide:(Required)
Is child #1 currently involved in any after school sports or academic programs?(Required)

Yes

No
List each activity:(Required)
List any reasons why they are not currently participating in after-school sports or activities:(Required)
Do you need to enter information for a 2nd child?(Required)

Yes

No
CHILD #2 INFORMATION
Child #2 Name:(Required)
First Last
Child #2 Date of Birth:(Required)
MM slash DD slash YYYY

Child #2 Age:(Required)
Child #2 Grade:(Required)
(Enter NA if not in school)
Caregiver Relationship to Child #2:(Required)

Grandparent

Other

Child #2 Greatest Need:(Required)
Child #2 Gender:(Required)

Female

Male

Decline
Child #2 Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Declined
Child #2 Race:(Required)

American Indian/ Alaska Native

Asian/Asian American

Black/African American

Native Hawaiian/Pacific Islander

White

Declined

Other

Is child #2 currently receiving services from any of the following:(Required)
(Check all that apply)
Medicaid
Medicare
SNAP
VA
TANF
Child Support from Father
Child Support from Mother
Social Security Benefits
How many years/months have you been caring for child #2?(Required)
Does child #2 have any learning impairments?(Required)

Yes

No
List any learning impairments below:(Required)
Is there anyone else that provides care for child #2?(Required)

Yes

No
List the provider and what type of support they provide:(Required)
Is child #2 currently involved in any after school sports or academic programs?(Required)

Yes

No
List each activity:(Required)
List any reasons why they are not currently participating in after-school sports or activities:(Required)
Do you need to enter information for a 3rd child?(Required)

Yes

No
CHILD #3 INFORMATION
Child #3 Name:(Required)
First Last
Child #3 Date of Birth:(Required)
MM slash DD slash YYYY

Child #3 Age:(Required)
Child #3 Grade:(Required)
(Enter NA if not in school)
Caregiver Relationship to Child #3:(Required)

Grandparent

Other

Child #3 Greatest Need:(Required)
Child #3 Gender:(Required)

Female

Male

Decline
Child #3 Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Declined
Child #3 Race:(Required)

American Indian/ Alaska Native

Asian/Asian American

Black/African American

Native Hawaiian/Pacific Islander

White

Declined

Other

Is child #3 currently receiving services from any of the following:(Required)
(Check all that apply)
Medicaid
Medicare
SNAP
VA
TANF
Child Support from Father
Child Support from Mother
Social Security Benefits
How many years/months have you been caring for child #3?(Required)
Does child #3 have any learning impairments?(Required)

Yes

No
List any learning impairments below:(Required)
Is there anyone else that provides care for child #3?(Required)

Yes

No
List the provider and what type of support they provide:(Required)
Is child #3 currently involved in any after school sports or academic programs?(Required)

Yes

No
List each activity:(Required)
Please list any reasons why they are not currently participating in after-school sports or activities:(Required)
Do you need to enter information for a 4th child?(Required)

Yes

No
CHILD #4 INFORMATION
Child #4 Name:(Required)
First Last
Child #4 Date of Birth:(Required)
MM slash DD slash YYYY

Child #4 Age:(Required)
Child #4 Grade:(Required)
(Enter NA if not in school)
Caregiver Relationship to Child #4:(Required)

Grandparent

Other

Child #4 Greatest Need:(Required)
Child #4 Gender:(Required)

Female

Male

Decline
Child #4 Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Declined
Child #4 Race:(Required)

American Indian/ Alaska Native

Asian/Asian American

Black/African American

Native Hawaiian/Pacific Islander

White

Declined

Other

Is child #4 currently receiving services from any of the following:(Required)
(Check all that apply)
Medicaid
Medicare
SNAP
VA
TANF
Child Support from Father
Child Support from Mother
Social Security Benefits
How many years/months have you been caring for child #4?(Required)
Does child #4 have any learning impairments?(Required)

Yes

No
List any learning impairments below:(Required)
Is there anyone else that provides care for child #4?(Required)

Yes

No
List the provider and what type of support they provide:(Required)
Is child #4 currently involved in any after school sports or academic programs?(Required)

Yes

No
List each activity:(Required)
Please list any reasons why they are not currently participating in after-school sports or activities:(Required)
SENIORS RAISING CHILDREN/OLDER RELATIVE CAREGIVER - PARTICIPATION AGREEMENT FORM
Please read the following information carefully, as it is an agreement between you and the Family Caregiver Support Program, which may have an impact on any financial support you may receive from the program.
Caregiver Name:(Required)
First Last
CAREGIVER AGREEMENT(Required)
I confirm that I have reviewed and fully understand all the statements listed below, and that they are true:
I confirm that I am solely responsible for the children listed on this application.

I certify that all of the information provided to the FCSP staff is accurate to the best of my knowledge.

I understand that no parents of child(ren) may be living in the home with child in order for them to be eligible for this funding.

I will inform FCSP staff of any changes to: address, phone number (including cell) of any and all participants in this program.

I understand that I must receive authorization for services from the FCSP before any funds can be dispersed.

As the FCSP is a consumer directed program, you may be requested to participate in interviews or surveys to measure client satisfaction and the effectiveness of the program. Should you not wish to participate, it will not affect your eligibility for the program or its benefits.
CAREGIVER CONSENT TO RELEASE INFORMATION(Required)
I confirm that I have reviewed and fully understand the statement listed below:
The information on this form is required by the local provider, the Area Agency on Aging (AAA), the South Carolina Lieutenant Governor’s Office on Aging and the U. S. Federal Government. The information provided will be kept confidential and guarded against unofficial use.

Some of the information gathered may be used to refer or provide appropriate services for client (such as referral for other services, emergency contact or sharing pertinent information to related service agencies for the purposes of planning services to meet the needs of the client.)

Some of the data asked for is required by either the South Carolina Lieutenant Governor’s Office on Aging and/or the U. S. Federal Government, as entities funding the services, and will be used for reporting and research. This data will not include the client’s name or identifying information and is aggregated. A client has the right to REFUSE to provide information. However, by refusing to answer particular questions, the client may be waiving his/her right to receive certain services.
Caregiver Signature(Required)
SIGNATURE IS REQUIRED TO RECEIVE SERVICES
Date of Signature(Required)
MM slash DD slash YYYY

If you would like to receive a copy of your completed application, please provide the email address to which you would like the application sent.
Enter Email Confirm Email

CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Seniors Raising Children/Older Relative Caregiver Application

As a part of the Family Caregiver Support Program, the Seniors Raising Children/Older Relative Caregiver Program assist seniors age 55 or older who are raising children. To qualify for the Seniors Raising Children/Older Relative Caregiver Program, there are several requirements that must be met. The child must be under the age of 18 and live in your home. The child’s parent cannot be residing in the home. The senior applying for assistance must provide a South Carolina-issued photo ID that includes their home address. The senior must submit supporting documentation from the court ordered custody or from an educational institution or an approved agency that verifies the home address of the minor(s). All criteria and documentation must be provided in order to receive assistance.

This field is hidden when viewing the form

FISCAL YEAR _ # ___

DO YOU QUALIFY FOR THIS PROGRAM?

To be considered for assistance, you must fulfill all five criteria listed below and submit all necessary documents.

Select all that apply.(Required)

Select all that apply.

1. The child is under the age of 18.

2. The child lives in my home.

3. The parent of the child is not residing in the home.

4. I have a South Carolina photo ID with my home address listed.

5. I can provide supporting documentation (e.g., court order, educational institution, or approved agency) verifying the home address of the minor(s).

CAREGIVER INFORMATION

Client Status:(Required)

New Client

Returning Client

Caregiver Name:(Required)

First Last

Caregiver Address:(Required)

Physical Address Mailing Address (if different from physical address) City State / Province / Region ZIP / Postal Code

Caregiver County:(Required)

Abbeville

Edgefield

Greenwood

Laurens

McCormick

Saluda

Caregiver Primary Phone:(Required)

Caregiver Secondary Phone

Caregiver Age:(Required)

Caregiver Date of Birth:(Required)

MM slash DD slash YYYY

Do you have Internet Access?(Required)

Yes

Caregiver Email:

CAREGIVER DEMOGRAPHICS

Caregiver Gender:(Required)

Female

Male

Decline

Caregiver Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Declined

Caregiver Race:(Required)

American Indian/ Alaska Native

Asian/Asian American

Black/African American

Native Hawaiian/Pacific Islander

White

Declined

Other

Caregiver Marital Status:(Required)

Married

Widowed

Divorced

Single

Domestic Partner/Civil Union

Number in Caregiver Household:(Required)

Caregiver Monthly Household Income:(Required)

CAREGIVER QUESTIONNAIRE

Are you currently employed?(Required)

Full-Time

Part-Time

Not Employed

Retired

How would you rate your emotional well-being?(Required)

Excellent

Good

Fair

Poor

Do you feel disconnected from child(ren) or feel it is difficult to communicate with child(ren)?(Required)

Yes

Please briefly describe circumstances that lead to your involvement of raising child(ren):(Required)

CHILD #1 INFORMATION

Child #1 Name:(Required)

First Last

Child #1 Date of Birth:(Required)

MM slash DD slash YYYY

Child #1 Age:(Required)

Child #1 Grade:(Required)

(Enter NA if not in school)

Caregiver Relationship to Child #1:(Required)

Grandparent

Other

Child #1 Greatest Need:(Required)

Child #1 Gender:(Required)

Female

Male

Decline

Child #1 Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Declined

Child #1 Race:(Required)

American Indian/ Alaska Native

Asian/Asian American

Black/African American

Native Hawaiian/Pacific Islander

White

Declined

Other

Is child #1 currently receiving services from any of the following:(Required)

(Check all that apply)

Medicaid

Medicare

SNAP

TANF

Child Support from Father

Child Support from Mother

Social Security Benefits

How many years/months have you been caring for child #1?(Required)

Does child #1 have any learning impairments?(Required)

Yes

List any learning impairments below:(Required)

Is there anyone else that provides care for child #1?(Required)

Yes

List the provider and what type of support they provide:(Required)

Is child #1 currently involved in any after school sports or academic programs?(Required)

Yes

List each activity:(Required)

List any reasons why they are not currently participating in after-school sports or activities:(Required)

Do you need to enter information for a 2nd child?(Required)

Yes

CHILD #2 INFORMATION

Child #2 Name:(Required)

First Last

Child #2 Date of Birth:(Required)

MM slash DD slash YYYY

Child #2 Age:(Required)

Child #2 Grade:(Required)

(Enter NA if not in school)

Caregiver Relationship to Child #2:(Required)

Grandparent

Other

Child #2 Greatest Need:(Required)

Child #2 Gender:(Required)

Female

Male

Decline

Child #2 Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Declined

Child #2 Race:(Required)

American Indian/ Alaska Native

Asian/Asian American

Black/African American

Native Hawaiian/Pacific Islander

White

Declined

Other

Is child #2 currently receiving services from any of the following:(Required)

(Check all that apply)

Medicaid

Medicare

SNAP

TANF

Child Support from Father

Child Support from Mother

Social Security Benefits

How many years/months have you been caring for child #2?(Required)

Does child #2 have any learning impairments?(Required)

Yes

List any learning impairments below:(Required)

Is there anyone else that provides care for child #2?(Required)

Yes

List the provider and what type of support they provide:(Required)

Is child #2 currently involved in any after school sports or academic programs?(Required)

Yes

List each activity:(Required)

List any reasons why they are not currently participating in after-school sports or activities:(Required)

Do you need to enter information for a 3rd child?(Required)

Yes

CHILD #3 INFORMATION

Child #3 Name:(Required)

First Last

Child #3 Date of Birth:(Required)

MM slash DD slash YYYY

Child #3 Age:(Required)

Child #3 Grade:(Required)

(Enter NA if not in school)

Caregiver Relationship to Child #3:(Required)

Grandparent

Other

Child #3 Greatest Need:(Required)

Child #3 Gender:(Required)

Female

Male

Decline

Child #3 Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Declined

Child #3 Race:(Required)

American Indian/ Alaska Native

Asian/Asian American

Black/African American

Native Hawaiian/Pacific Islander

White

Declined

Other

Is child #3 currently receiving services from any of the following:(Required)

(Check all that apply)

Medicaid

Medicare

SNAP

TANF

Child Support from Father

Child Support from Mother

Social Security Benefits

How many years/months have you been caring for child #3?(Required)

Does child #3 have any learning impairments?(Required)

Yes

List any learning impairments below:(Required)

Is there anyone else that provides care for child #3?(Required)

Yes

List the provider and what type of support they provide:(Required)

Is child #3 currently involved in any after school sports or academic programs?(Required)

Yes

List each activity:(Required)

Please list any reasons why they are not currently participating in after-school sports or activities:(Required)

Do you need to enter information for a 4th child?(Required)

Yes

CHILD #4 INFORMATION

Child #4 Name:(Required)

First Last

Child #4 Date of Birth:(Required)

MM slash DD slash YYYY

Child #4 Age:(Required)

Child #4 Grade:(Required)

(Enter NA if not in school)

Caregiver Relationship to Child #4:(Required)

Grandparent

Other

Child #4 Greatest Need:(Required)

Child #4 Gender:(Required)

Female

Male

Decline

Child #4 Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Declined

Child #4 Race:(Required)

American Indian/ Alaska Native

Asian/Asian American

Black/African American

Native Hawaiian/Pacific Islander

White

Declined

Other

Is child #4 currently receiving services from any of the following:(Required)

(Check all that apply)

Medicaid

Medicare

SNAP

TANF

Child Support from Father

Child Support from Mother

Social Security Benefits

How many years/months have you been caring for child #4?(Required)

Does child #4 have any learning impairments?(Required)

Yes

List any learning impairments below:(Required)

Is there anyone else that provides care for child #4?(Required)

Yes

List the provider and what type of support they provide:(Required)

Is child #4 currently involved in any after school sports or academic programs?(Required)

Yes

List each activity:(Required)

Please list any reasons why they are not currently participating in after-school sports or activities:(Required)

SENIORS RAISING CHILDREN/OLDER RELATIVE CAREGIVER – PARTICIPATION AGREEMENT FORM

Please read the following information carefully, as it is an agreement between you and the Family Caregiver Support Program, which may have an impact on any financial support you may receive from the program.

Caregiver Name:(Required)

First Last

CAREGIVER AGREEMENT(Required)

I confirm that I have reviewed and fully understand all the statements listed below, and that they are true:

I confirm that I am solely responsible for the children listed on this application.

I certify that all of the information provided to the FCSP staff is accurate to the best of my knowledge.

I understand that no parents of child(ren) may be living in the home with child in order for them to be eligible for this funding.

I will inform FCSP staff of any changes to: address, phone number (including cell) of any and all participants in this program.

I understand that I must receive authorization for services from the FCSP before any funds can be dispersed.

As the FCSP is a consumer directed program, you may be requested to participate in interviews or surveys to measure client satisfaction and the effectiveness of the program. Should you not wish to participate, it will not affect your eligibility for the program or its benefits.

CAREGIVER CONSENT TO RELEASE INFORMATION(Required)

I confirm that I have reviewed and fully understand the statement listed below:

The information on this form is required by the local provider, the Area Agency on Aging (AAA), the South Carolina Lieutenant Governor’s Office on Aging and the U. S. Federal Government. The information provided will be kept confidential and guarded against unofficial use.

Some of the information gathered may be used to refer or provide appropriate services for client (such as referral for other services, emergency contact or sharing pertinent information to related service agencies for the purposes of planning services to meet the needs of the client.)

Some of the data asked for is required by either the South Carolina Lieutenant Governor’s Office on Aging and/or the U. S. Federal Government, as entities funding the services, and will be used for reporting and research. This data will not include the client’s name or identifying information and is aggregated. A client has the right to REFUSE to provide information. However, by refusing to answer particular questions, the client may be waiving his/her right to receive certain services.

Caregiver Signature(Required)

SIGNATURE IS REQUIRED TO RECEIVE SERVICES

Date of Signature(Required)

MM slash DD slash YYYY

If you would like to receive a copy of your completed application, please provide the email address to which you would like the application sent.

Enter Email Confirm Email

CAPTCHA

This field is for validation purposes and should be left unchanged.