StartUP Respite Grant Program Application Instructions

*Required 

1. Program Name *

2. Organization name (if different from Program Name)

Is your entity registered with the Wisconsin Department of Financial Institutions (WDFI) https://dfi.wi.gov/Pages/Home.aspx? Please note, IF your application is approved, RCAW requires all grantees to register with WDFI before their 6-month progress report is due *

3. Website (if available)

4. Address *

5. City *

6. State *

7. ZIP code *

8. Contact Name *

9. Title *

10. Email address *

11. Phone number *

12. A key team member of the Business/Program must have completed the Bringing Respite to Your Community (BRYC) Workshop.

List: 1.) Name, 2.) Date completed, *

13. Date of application *

Please input the date (m/d/yyyy)

14. Amount Requested ($5,000 – $25,000) *

15. Program Summary: In 250 words or fewer, provide a high-level overview of the respite Think elevator speech. An elevator speech is a concise, compelling summary of who you are and what you do, typically delivered in 30-60 seconds, designed to be memorable and leave a lasting impression. *

Specific Program Information

Please enter information regarding the specific program for which the funds are requested. If this is a new program for an existing agency (expansion program), share information about the new program, not the already established program. Please address all the questions with the open-response questions. Otherwise, the application may be considered incomplete.

16. Is this a new respite program/business or a new program expanding an existing direct service program/business? *
    • New program/business
    • New program/business/location as part of an existing program/business (expansion)

17. Answer these questions if this new program is starting as part of an existing

• How long has the existing business been operating? How does this new program fit into the existing business?
• How is this new program different from existing services?

18. Program Model: What is the best description of your respite program model? Please check all that *

• Home-Based Programs (in-home services)
• Community-Based Services (facility)
• Crisis/ Emergency Respite
• Camps
• Residential Facility
• Intergenerational Centers
• University Respite Program
• Other:

19. What services will be offered by this program? Please use specific service billing names if *

20. Will this program need licensing or certification? Please list which licensing/certification program you will receive. What is the status of the license or certification process? *

21. Please list the counties your program will serve (the counties where participants reside). *

22. Client Population: What ages will this program serve? (Choose all that ) *

• Children under 5 years old
• School-age children 5-21 years old
• Adults under 55 years old
• Older Adults 55+ years old

23. Describe the client population (specific disabilities, level of care, medical needs, behavioral needs, ) the program will serve. Include if there are any limitations on who you may not be able to serve (i.e., individuals with a tracheotomy, individuals who need medications, individuals who can be aggressive towards others, individuals who need assistance with toileting, etc.). *
24. Describe your initial program Include how often and when participants will be able to use your program (what days/hours are you open, daytime or overnight care, how long is a session (of hours) for a participant, how many sessions/hours can a participant have in a week/month, etc.). *

25. After a year of program operation, do you anticipate any changes to the program hours, availability, and limits for participant sessions/hours, etc.? *
26. Facility Information: Please choose all that *
    • This program does not provide services in a
    • This program will rent a
    • This program will own a
    • This program has secured a
    • Other:
27. What staff/volunteer-to-client ratio does the program anticipate having? *
28. Who are the key staff members, and what are their roles? How many team members are currently involved in this program, and in what roles (paid/unpaid)? *

Funding

Please enter information regarding the specific program for which the funds are requested. If this is a new program for an existing agency (expansion program), share information about the new program, not the already established program. Please address all the open-response questions; otherwise, the application may be incomplete.

29. For what will the requested grant funds specifically be used? *
30. Once the program provides services, what funding streams will this program use? Choose all that *
    • Private Pay
    • Long-Term Care Waiver/ Medicaid
    • insurance
    • Grants
    • Fundraising
    • Other:
31. What is the sustainability plan for this program? Please be specific. *

Additional Information

Please enter information regarding the specific program for which the funds are requested. If this is a new program for an existing agency (expansion program), share information about the new program, not the already established program. Please address all the questions with the open-response questions. Otherwise, the application may be considered incomplete.

32. Need for Program: How do you know there is a need for this program in your community? (Needs analysis results, letters of support from community members, caregivers, county agencies, funding sources, etc.) Supporting documentation can be attached to your budgets. *
33. Timeline: Provide a timeline of key milestones and dates, e., what needs to happen for services to start and when. *

34. Marketing: How will participants, families, and funding sources learn about this program? *

35. Additional Comments: Share any additional comments regarding this

Budget Templates and Supporting Documentation

For your application to be complete, you must email the following items to [email protected]

2. Start-Up Budget – Template A
3. Annual Budget – Template B
4. Attach any information supporting this program’s need in your community. This may include a needs analysis, letters of support from community members, family caregivers, respite care providers, county agencies, funding sources, or other relevant materials.

Important

You must follow the submission instructions for budgets and supporting documents exactly. This is a highly competitive grant, and RCAW receives many emails from applicants. If budget templates and supporting documents are sent without the required information in the email, we won’t know which program they belong to. As a result, they will not be considered during the grant review process.

All attachments must be in Excel or PDF format. Email the budget templates and supporting documentation to [email protected].

Submission Requirements

1. Use “Start-Up Funds Application” as the subject
2. Include your first and last name, as well as your program name, in the body of the
3. Save all attachments using your program name in the file For example:
   • Forest Venture’s Budget Template A
   • Forest Venture’s Budget Template B
   • Forest Venture’s Needs Analysis
   • Forest Venture’s Letter of Support