CAREGIVERS

Are You a Caregiver in Need of a Break?

Let ILRCC help you find the support you need.

At the Independent Living Resource Centre of Calgary (ILRCC), we know how essential it is for caregivers to have time to rest and recharge. That’s why our Respite Program is here—to help connect families with respite workers who can offer short-term, flexible support.

By completing our application, you’ll take the first step toward being matched with a respite worker from our trusted database, based on your family’s unique needs.

Whether it’s for a few hours, a day, or occasional breaks, respite care provides you with time to care for yourself—while your loved one continues to receive safe, supportive care in your home, the worker’s home, or out in the community.

📝 Complete the application today and start receiving the support your family deserves!

All information shared is kept strictly confidential and securely stored.
We’re here to walk this journey with you—because you matter, and so does your well-being.

Welcome to the Independent Living Resource Centre of Calgary’s (ILRCC) Respite Program. We appreciate you taking the time to complete this application—it’s the first step toward finding the right respite worker for your family! Our goal is to provide quality respite care that allows you to rest and recharge, while ensuring your loved one continues to receive safe and supportive care. All information collected in this questionnaire will be kept strictly confidential and securely stored. * The Respite Workers listed in our database provide short-term, occasional support —they do not oﬀer full-time or continuous daily care like a day program. The purpose of respite care is to give family caregivers a much-needed break, whether for a few hours, a day , or longer. This support may happen in your home, the respite worker’s home, or through community outings. If you have any questions, comments, concerns, or need help filling out the application please contact: ILRCC Respite Coordination Staﬀ 403-263-6880 respite@ilrcc.ab.ca

*** Please note that all the information gathered in this questionnaire is kept secured. ***

General Applicant Information

1. Name(Required)

First Last

Preferred Name(Required)

2. Phone(Required)

3. Email(Required)

4. What is your preferred method of contact?(Required)

By email

By phone

By text

No preference

5. What is your relationship to the person requiring respite care?(Required)

6. What is the reason that you are seeking respite care at this time?(Required)

7. How did you originally hear about our Respite Worker Database?(Required)

ILRCC website

Job searching website (e.g. LinkedIn, Indeed, Glassdoor)

Friend/family/colleague

Google Search

School/University/College

Other (please specify)

Other

Family members/loved ones information

8. Name of loved one requiring respite care(Required)

First Last

Preferred name (if applicable)

9. Phone (if diﬀerent from above)

10. Email (if diﬀerent from above)

11. Type of Disability: (Check all the apply)(Required)

ADHD

Autism Spectrum Disorder

Blind

Cerebral Palsy

Deaf

Deafblind

Down Syndrome

Dyscalculia

Dysgraphia

Dyslexia

Epilepsy

Hard of Hearing

Intellectual Disability

Invisible Disability

Learning disabilities

Mental Disorder

Multiple Disabilities

Multiple Sclerosis

Muscular Dystrophy

Neurological Disorder

Physical Disability

Spinal Cord Injury

Traumatic Brain Injury

Vision impairment

Other

Other Disability

Preferences

12. What languages are spoken at home? (check all that apply)(Required)

English

French

Punjabi (Panjabi)

Mandarin

Arabic

Yue (Cantonese)

Spanish

Tagalog (Pilipino, Filipino)

Italian

German

Urdu

Portuguese

Hindi

Russian

Vietnamese

Iranian Persian

Tamil

Korean

Polish

Gujarati

Serbo-Croatian

Greek

Bengali

Romanian

Ukrainian

Dutch

Malayalam

Haitian Creole

Dari

Serbian

Hungarian

Turkish

Japanese

Cree, n.o.s.

Croatian

Somali

Ilocano

Telugu

Armenian

Inuktitut

Tigrigna

Min Nan (Chaochow , Teochow , Fukien, Taiwanese)

Plautdietsch

Albanian

Amharic

Kabyle

Persian (Farsi), n.o.s.

Nepali

Yoruba

Other (please specify)

Other language

The next 2 questions are for matching purposes only and do not guarantee that these preferences will be met.

13. If important to you, please feel free to share your religion with us.

14. Are you looking for a specific gender for your Respite Worker

Yes

15. Please let us know what respite worker gender you prefer and why(Required)

16. Is your loved one (check all that apply)(Required)

Independent

Semi-independent

Dependent

In a wheelchair and needs transfer support

In a wheelchair but does not need transfer support

Aggressive

Complex needs

Other (please specify)

Other Needs

17. Is there anything else you would like us to know about your family or your loved one?

Needs

Respite Workers provide short-term, occasional support—they do not oﬀer full-time or continuous daily care like a day program. The purpose of respite care is to give family caregivers a much-needed break, whether for a few hours, a day , or longer. This support may happen in your home, the respite worker’s home, or through community outings.

18. What types of respite services do you require? (check all that apply)(Required)

Personal Care

Medication Assistance

Participation in Community (e.g. community based groups, recreation or leisure activities etc.)

Light Housekeeping Duties

Companion Care

Meal Preparation

Appointment/errand Support

Overnight Care in Your Home

Overnight Care in Respite Workers Home

Other (please specify)

Other care required

Monday

Overnight

Tuesday

Overnight

Wednesday

Overnight

Thursday

Overnight

Friday

Overnight

Saturday

Overnight

Sunday

Overnight

Other Times