Application Submission: Complete and submit the application form below with all required information.
Initial Review: Our team reviews your application to verify completeness and eligibility criteria.
Medical Verification: We may contact your healthcare provider to confirm medical circumstances and needs.
Funding Assessment: We evaluate current funding availability and prioritize based on urgency and need.
Getaway Planning: If approved, we'll work with you to schedule and coordinate your respite.
Approval Decision: If we are unable to place your family, we will notify you and provide information on reapplication or waitlist options.

No Guarantee: Charted Way Foundation does not guarantee approval of respite applications. Each application is carefully reviewed on a case-by-case basis.
Approval Authority: Charted Way Foundation reserves the right to approve or decline any respite application for any reason, including but not limited to funding availability and eligibility requirements.
Funding Dependent: All respites are subject to available funding. We operate on donations and grants, which may vary throughout the year.
Urgency Priority: Applications are prioritized based on medical urgency, family circumstances, and the severity of need.
Honest Information: All information provided must be accurate and verifiable. False or misleading information may result in immediate disqualification.

Apply for a Respite

Fill out the form below to begin your application. We'll review it and be in touch soon.

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Home Phone

Cell Phone *

Work Phone

Email *

Relationship to Family Member *

Family Member First Name *

Family Member Last Name *

Diagnosis * Please provide details about the medical condition

Date of Diagnosis *

End of Treatment Date If applicable

Date of Birth *

Length of Stay

Long Weekend (3-4 days)

Full Week (7 days)

Preferred Season(s)

Spring (March - May)

Summer (June - August)

Fall (September - November)

Add me to the cancellation list

If selected, we'll contact you when last-minute openings become available, which may allow for earlier getaway dates.

Emergency Contact * Name and phone number

Have you received services from ChartedWay before? *

Yes

Special Instructions or Requests Any dietary restrictions, accessibility needs, or other special requests

How Did You Hear About Us?

* Required fields. We'll review your application and contact you within 3-5 business days.

Questions about the application process?