Child and Family Services of Central Manitoba

Respite Inquiry – Intake Form

If you are interested in becoming a Respite Provider, please fill out the below inquiry form and we will contact you. PDF Inquiries can be sent to

When completed please contact: 204-857-8751

Required fields that do not apply can be filled as ‘none’ or ‘not applicable’ (NA).

"*" indicates required fields

Applicant's DOB*
Partner/Spouse's DOB
Home Address*
Date of Marriage or Common Law*
Respite for what age and gender of child(ren)
Date of Inquiry*