LOCATED ONLY in UTAH. Please complete the below form to apply for the Kids On The Move Respite Care Program. By providing your mobile phone number, you are giving Kids on the Move permission to contact you via voice or text.
To be eligible for the respite program, the following must be true: Care giver does not receive any government funding including DSPD, Medically-Complex Waiver, or shared parental custody or any other consistent respite care, including having extended family watch the child. Child is not considered medically fragile and does not need extensive nursing care at respite. Child can be cared for by a volunteer under a nurse's supervision. Child is not violent or aggressive toward others (staff, volunteers, and other children are not at risk of being harmed by the child). Child is able to attend respite from 6-9 pm, pick up before 8:30 is discouraged since volunteers are committed to being at respite and often need/want service hours for class requirements or applications.
Parent/Guardian
LOCATED ONLY in UTAH. If you have any difficulty filling out this application, please call Kids On The Move Respite Care Director, 801-221-9930, Ext. 207.
First Name (Required)
Last Name (Required)
Birthday (Required)
Email Address (Required)
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
Home Phone
Work Phone
Ext.
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody (Required)
Yes
No
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
Click here
to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
Birthday (Required)
Email Address
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
Home Phone
Work Phone
Ext.
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Other Adults
Are there other adults in the household?
Add Another Adult
Family Information
Number of Parents/Guardians
One Parent Family
Two Parent Family
Relationship to Participant(s)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home
American Sign Language
English
Spanish
Number in Family
Gross Annual Income
Child (Applicant)
IN THE LAST TEXT BOX THAT SAYS "Is there anything else you want to tell us about your child?" PLEASE LIST YOUR CHILD'S DIAGNOSIS/DISABILITY; AND, ALSO, TELL US HOW RESPITE WOULD BENEFIT YOU AND YOUR FAMILY. THANK YOU!
First Name (Required)
Last Name (Required)
Nickname
Birthday (Required)
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Doctor/Medical Home
Adrianne R. Walker-Jenkins, MD
Alpine Pediatrics
Alyson E. Edmunds, MD
Amanda Jocelyn, MD
Benjamin Greenfield, MD
Bradley C. Arnold, MD
Bradley W. Anderson, MD
Brady Watkins, PA-C
Bret T. Muse, MD
Brian C. McCune, MD
Bryce Carter, MD
Cathy Johnson, C-PNP
Cindy Brough, MD
Clint R. Nelson, MD
Community Health Centers, Inc.
D. Todd Whiting, M.D.
Darden Swords, MD
David Bush, MD
Doug Later, MD
Elizabeth Dayton, MD
Erika Seaquist, MD
Ernest Bailey, MD
Galina Hornyik. MD
Garrett Smith, MD
Garron E. Miller, MD
Greg M. Pavich, MD
Gregory Wynn, MD
Heather Benally, PA-C
Jacqueline Giannini, MD
Jared Bingham, MD
Jason Hoagland, MD
Jeff Jackson, MD
Jeffrey A. Penman, MD
Jeffrey H. Abram, PA-C
Jeffrey L. Jensen, MD
Jeremy R. Hadley, MD
Jesse Alba, MD
John Bennett, MD
John Wynn, MD
Jonathan P. Peterson, MD
Jonathan R. Burnett, MD
Jonathan W. Schmidt, MD
Jonathen Bartholomew, MD
Joseph Hershkop, MD
Joseph M. Johnson, MD
Joshua Fuller, MD
Julia C. Brogli, MD
Karla Feindt. MD
Katherine Lavender, MD
Kathleen McElligott, MD
Kathleen O'Mara, MD
Kathy S. Garcia, MD
Kenneth A. Zollo, MD
Kerri N. Smith, DO
Kody Crowell, MD
Kristi K. Ice, MD
Landon Hendricks, MD
Marcie Conner, MD
Mark J. Devenport, MD
Mark Rowan, MD
Matt Allen, MD
Matthew Clayton, MD
Michael Fullmer, MD
Michael H. Lauret, MD
Michael Kennedy, MD
Michael Whiting, MD
Mitzi Conover, MD
None At This Time
Patrick McVey, MD
Philip N. Isenberg, MD
R. Mitchell Adams, MD
Rachel Woods, MD
Rajiv J. Kaddu, MD
Richard Paxton, MD
Scott H. Mumford, MD
Scott Peterson
Stephen Lee, MD
Steven Berry, MD
Steven L. Embley, DO
Steven L. Jones, R.N.,MSN,N.P.-C
Tim Hoggard, MD
Timothy Larsen, MD
Tony Bitters, PA
Tonya Jackson, MD
Tyson Jones, MD
Weston E. Spencer, MD
Dentist/Dental Home
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
2023-2024
Location Preference
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1st Location Preference
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2nd Location Preference
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3rd Location Preference
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- Your Address
- Available Locations
Click a location on the map to see more info
Click here
to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Required information is missing, see above.