Carer Holiday Grant Form - The 3H Foundation

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SECTION A: PERSONAL DETAILS

Details of Applicant/Carer

Title

First Name

Last Name

Address Line 1

Address Line 2 (optional)

Town

County

Post Code

Home Telephone Number

Mobile Telephone Number

Email Address

Details of Cared for Person

Title

First Name

Last Name

Date of Birth

Age

Main disabilities of the cared for person

Relationship to you: e.g. Mother/Son

Their address if different from above

Tel No

Email Address

Section B: Please answer the following

You are the main unpaid carer of the disabled person you care for?

You are in receipt of a means tested benefit (e.g. Universal Credit/Pension Credit)?

You are in receipt of carers allowance?

The grant will be used for the carer to have a break while the person you care for will be looked after at home.

Have you had a holiday this year by any other means?

Have you lived in the UK for 6 Months or more?

The definition of disability means: 'A physical or mental impairment that has a substantial and long-term effect on your ability to do normal daily activities.' Note:'Substantial' means more than minor or trivial, e.g. It takes longer than usual to get dressed. Long-term means for 2 months or more.

Does the person with the disability meet the 'definition of disability' from the Equality Act?

When was your last break away from the person you care for? (Year)

Is the person you care for in receipt of Attendance Allowance, DLA or PIP?

Section C: Proposed Holiday

Please note that grants are for the ACCOMODATION part of a holiday and are only awarded for holidays taken in the UK. Payment is made by BACS directly to the holiday venue/organisation. We will NOT issue payments directly to the applicant.

Please confirm the holiday will be taken in the UK.

Month of the proposed holiday

Please confirm the name, address and relationship of the person you are taking with you or if you are going alone. Grants are for a maximum of two people.

Name

Address

Relationship

If the cost of the holiday is more than the amount of the grant applied for, please advise how will you pay for the shortfall (e.g. Other funding applications, Social Services, Funding yourself).

Section D: Your Situation

What type of care/support do you provide and how many hours a week?

What aspects of your life are affected due to your caring role (such as health/emotional/social aspects)?

Section E: Income Details

Please write in the weekly/monthly amount you receive for EACH benefit/source of income.

Please include amounts for ALL household members that receive benefits/income. If no benefit is received, please put a '0'.

Universal Credit BEFORE ANY DEDUCTIONS

Per week or month?

Carer's Allowance

Per week or month?

Disability Living Allowance/PIP

Per week or month?

Employment Full or Part Time Work

Per week or month?

Employment and Support Allowance (ESA)

Per week or month?

Housing Benefit

Per week or month?

Pension

Per week or month?

Pension Credit

Per week or month?

Child Benefit

Per week or month?

Maintenance

Per week or month?

Other Income/Benefits - Such as State Pension

Per week or month?

How many adults are in your household?

How many children are in your household? (0-17 years or adults in further education)

Any other low-income information you wish to tell us about.

Please upload a photo of your complete latest Universal Credit statement or Pension Credit statement here. (All pages)

Maximum file size: 33.55MB

If we are able to proceed, evidence of all of your benefits will be required such as letters from the benefit agencies and copies of 1 month's recent bank statements for all adults living in your household.

Declaration

Please note that If you have already booked and paid for a holiday, we will NOT be able to award you a grant. The grants we offer are modest grants of no more than £300.

To the best of my knowledge the above information is correct, and I agree to The 3H Foundation's Terms and Conditions.

Yes (These can be found on our website)

I understand that to comply with the Data Protection Act 2018 and for The 3H Foundation to administer my/our application, I/we give permission for The 3H Foundation to keep this information on file. All my personal data will be kept confidentially by The 3H Foundation for a time deemed necessary. The 3H Foundation will forward your personal data to the necessary parties who will have been made aware of their obligations to abide to all aspects of the new data regulations and particularly in respect of confidentiality and safe keeping.

We may use feedback or details to help improve our service, report back to donors or for promotional purposes using a first name or initial only. Please let us know if you prefer your comments not to be used.

I give permission for The 3H Foundation to publish any photographs in newsletter, leaflets, on their website and/or for reporting back and promotional purposes. (this will be in first name format only)

Yes

No

We will require you complete a post-holiday questionnaire to aid future grants and support fundraising.

Name

Date

Would you like to be added to our mailing list?

Yes

No

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Carer Holiday Grants Application Form

SECTION A: PERSONAL DETAILS

Section B: Please answer the following

Section C: Proposed Holiday

Section D: Your Situation

Section E: Income Details

Declaration