DA Form 5187 Application for Respite Caregivers

DA Form 5187 - also known as the "Application For Respite Caregivers" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 5187 - was last revised on June 1, 2009. Download an up-to-date fillable PDF version of the DA 5187 below or request a copy through the chain of command.

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APPLICATION FOR RESPITE CAREGIVERS
For use of this form, see AR 608-75; the proponent agency is OACSIM
DATA REQUIRED BY THE PRIVACY ACT
Title 5, United States Code, Section 301.
AUTHORITY:
To recruit and select respite caregivers.
PRINCIPAL PURPOSE:
To determine the prospective respite caregiver's ability to care for individuals with disabilities.
ROUTINE USES:
Providing information is voluntary. Failure to provide information will result in disapproval of prospective respite
DISCLOSURE:
caregiver's application.
1. NAME
2. BIRTHDATE
3. MAIDEN NAME (Applicant or spouse)
4. SPOUSE'S NAME
5. ADDRESS (Street, city and state) (Include ZIP Code)
6. TELEPHONE NO.
HOME:
OFFICE:
7. BRIEFLY DESCRIBE BACKGROUND, INTEREST, AND/OR EXPERIENCE WORKING WITH CHILDREN OR ADULTS WITH DISABILITIES
8. AVAILABILITY FOR PROVIDING CARE
EVENINGS
YES
NO
WEEKENDS
YES
NO
DAYS
YES
NO
OVERNIGHT WEEKDAYS
YES
NO
OVERNIGHT WEEKENDS
YES
NO
WILL PROVIDE CARE:
IN HOME OF CLIENT
IN MY OWN HOME
NO PREFERENCE
9. DO YOU HAVE OWN TRANSPORTATION?
10. AGE GROUP PREFERENCE
YES
NO
11. EDUCATION (High school, college, graduate studies, other)
NAME AND ADDRESS OF SCHOOL
DATES ATTENDED
MAJOR
DEGREE
12. EMPLOYMENT (Present, and last three years)
NAME AND ADDRESS OF EMPLOYER
DATES EMPLOYED
POSITION
13. REFERENCES (List three, other than relative. Example: Pastor, supervisor, co-worker)
NAME AND ADDRESS (Give complete mailing address) (Include ZIP Code)
OCCUPATION
I hereby certify that all statements in this application are true to the best of my knowledge and belief.
SIGNATURE
DATE (YYYYMMDD)
DA FORM 5187, JUN 2009
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00ES

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