My Respite Plan

Here is a blank form for your use to help you plan your respite hours for the year.

This is a sample, you can print the document here: My Respite Plan.pdf (53055 B)

Respite Funds: $__________ Special Service at Home Funds: $__________ Other: $ __________ Number of hours of respite available to me (is the total number of hours divided by the Respite contractor rate I wish to pay) How I plan to use my respite hours:
My regular weekly respite (what do I need to do? What would I like to do?)
Monday	Tuesday	Wednesday		Thursday	Friday	Total hrs	Total hours
							Total number of hours x 52 weeks
Regular weekend respite (what do I need to do? What would I like to do?)
Saturday			Sunday			Total hours per weekend	Total hours
							Total number of hours x 52 weeks
Do I need to plan for school and/or additional respite for summer holidays? (over and above regular weekly respite)
Monday	Tuesday	Wednesday		Thursday	Friday	Total hours per week	Total hours
							Total number of hours x 10 weeks
Do I need additional respite for Christmas ?(over and above regular weekly schedule)
Monday	Tuesday	Wednesday		Thursday	Friday	Total hours per week	Total hours
							Total number of hours x 2 weeks
Do I need additional respite for March Break ?(over and above regular weekly schedule)
Monday	Tuesday	Wednesday		Thursday	Friday	Total hours per week	Total hours
							Total number of hours x 1 week
Other needs? (school: pd day/exam days, medical appointments, special occasions….)
Number of hours/day			Number of days			Total hours	Total hours
							Total number of hours

Provincial Respite Services Network 2018 Update