Summer Recreation and Respite Application

Please complete the following application for Summer Recreation and Respite for the 2023 Summer season.

Before you begin, please be sure to have the following information ready:

  • Emergency contact information
  • Medicaid number and Tabs number
  • Other Insurance information (if applicable)
  • Diagnosis, allergies and medications
  • Care Manager contact information
  • Self Direction Support Broker and Fiscal Intermediary contact information (if applicable)
  • Participants interests and fears
  • Participants medical or dietary precautions, and adaptive equipment needs (including for transportation)
  • OPWDD Eligibility Letter (to upload)
  • Last two Life Plans (to upload)
  • Current Level of Care (to upload)
  • Service Authorization (if applicable) (to upload)
  • Self- Direction Budget (if applicable) (to upload)

If you have any questions, please contact Korin Karszen at