This application is the first step in the reservation process. Current IEP and/or medical documentation of a life-threatening illness is required and provides a baseline for determining your eligibility.

Please fill out the application below as thoroughly as possible to help us determine your eligibility. Once determined and space is available, we will be in touch to schedule your stay. If you are a single parent you are welcome to attend alone, bring a friend who has a child with special needs or a life threatening illness, or bring a significant other who lives in your home and assists in caring for your child.

*Please complete each field. Also, if you have previously been a Restore Place guest you must complete a new application each time you wish to make a reservation.

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name and Age of child/children with disability or life-threatening illness

Names and ages of other children at home

Name of spouse, significant other or additional caretaker in the home

My child has

A life-threatening illness

Special needs

Both

Does your child live with you at home 7 days/week?

Yes

If no, please explain under lever of care below.

Please describe in detail your child's medical diagnosis

Medical Needs

If applicable, please describe the level of care you provide for your child in this area (the more detail you provide, the easier it will be to process your application)

Hospitalization

What is the most challenging part of having a child with special needs or life threatening illness?

Who is your Service Coordinator/Medicaid Waiver Coordinator? (name, phone number, and agency)

Please share with us any family, friend, or community supports that are currently in place.

How often do you get away without your children (include the last time you were away overnight)? If you are a past guest, how has your time at Restore Place inspired you to spend more time caring for yourself/yourselves??

What do you hope to experience at Restore Place?

Do you have any accessibility concerns or severe pet allergies that would affect your location? (many B&B's are not handicapped accessible and some innkeepers have pets)

How did you hear about Restore Place?

To complete this application, please send 1) a current photo of your household and 2) a copy of your child's IEP or medical documentation (may be a Doctor's note) in the following format

Email: info@restoreplace.org

Mail: Restore Place, PO Box 2241; Woodstock, GA 30188

Is there anything else you would like to share with us that will help determine your eligibility?

Preferred Destination Location

Under Georgia Law, there is no liability for an injury, sickness or death of an individual entering any Restore Place destination location. This includes inherent risks of contracting Covid-19. You are assuming this risk by entering these premises.

Confirm Agreement to above stated risks

If you are not sent to the thank you page after submitting this form please check that all the required fields are filled in.

Do you have questions or need more information?

Call us at 770-693-1462 or email: info@restoreplace.org.

Application

If you are not sent to the thank you page after submitting this form please check that all the required fields are filled in.