New Family Registration

Welcome! We’re glad you’re here and look forward to supporting your family with caring, dependable respite services. Completion of this registration does not guarantee the start of services. All youth must have a care coordinator through OhioRISE and an approved care plan that includes scope, frequency, and duration before services can begin.

Guardian's First Name

Guardian's Last Name

Type of Phone

Guardian's Phone Number

Allow Communication via Texting

YesNo

I am a resident of Ohio

YesNo

Street Address

City

County

State

Zip

Create a Login

Username (Email Address)

Password

Password should be at least 10 characters, with at least 1 uppercase, 1 lowercase, and 1 special character.

CONFIRMATION: I certify that my answers are true and complete to the best of my knowledge. I certify I understand that this program is for youth registered in OhioRise only. If your youth is no longer a part of OhioRise we will not be able to provide services.

I agree to the Guardian-Respite Provider Service Agreement and acknowledge that I have read, understand, and agree to the terms of this Agreement.

Signature Clear

Date