Carer Holiday Grant Form - The 3H Foundation

Where did you here about us?

Please select a location category.

Details of the 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

Please confirm the following:

Are you the main unpaid carer of the disabled person?

Do you receive carers allowance?

Please confirm the grant will be used for the carer to have a break while alternative provision is made for the person you care for.

Are you having a respite holiday this year by any other means?

Full Details of the person with disabilities

Title

First Name

Last Name

Full address including postcode

Date of Birth

Your relationship to the person with the disability

What disabling condition(s) does the person with disabilities have?

Eligibility

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

Do you have a household income of £35,000 or less, including benefits, pensions and wages etc? (We include income for ALL those in the home where applicable)

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?

Holiday

Grants are for the ACCOMODATION part of a holiday only, are awarded for household family members and, if necessary, a carer attending the holiday. Payment is made directly to the holiday venue/organisation by bank transfer. We will NOT pay grants directly to applicants.

Please confirm the holiday will be taken in the UK.

Please confirm the name, address and relationship of the person you are taking with you (max 1 person) or if you are going alone.

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

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

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

Financial

Low income threshold information: If your TOTAL ANNUAL HOUSEHOLD income is less than £35,000, you may be eligible to apply for a grant. We include PIP and DLA in this figurePlease write in the amount you receive in each benefit box. If you do not receive a benefit, put a 0.Please write the amount and select whether this is per week/month.

Income Support

Per week or month?

Working Tax Credits

Per week or month?

If you receive working tax credits, please ensure you detail income in the full or part time work section.

Child Tax Credits

Per week or month?

Jobseeker's Allowance

Per week or month?

Incapacity Benefit

Per week or month?

Pension Credit

Per week or month?

Universal Credit

Per week or month?

Housing Benefit

Per week or month?

Is the housing benefit paid directly to your landlord?

Full or Part Time Work

Per week or month?

How many hours per week?

Disability Living Allowance/PIP

Per week or month?

Employment and Support Allowance (ESA)

Per week or month?

Child Benefit

Per week or month?

Carer's Allowance

Per week or month?

Maintenance

Per week or month?

Other Income/Benefits - Such as State Pension

Per week or month?

Please add any other low-income information you wish to tell us about.

How many adults are in your household?

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

Declaration

If we are able to proceed, evidence of all of your benefits will be required such as letters from the benefit agencies or copies of 1 months recent bank statements. If you have already booked and paid for a holiday, we will NOT be able to award you a grant. The grants we offer modest grants of no more than £550.

To the best of my knowledge the above information is correct

Yes

I give permission for The 3H Foundation to publish any photographs and comments with my first name and for reporting back to funders and for promotional use.

Yes

No

I agree to The 3H Foundation's terms and conditions. (These can be found on our website or requested separately)

Yes

I understand that under the General Data Protection Regulations (GDPR) and for The 3H Foundation to process my/our application, I/we give permission for you to keep this information on file. All my personal data will be kept confidentially by 3H for a time deemed necessary. 3H will forward my personal data to the necessary parties who will have been made aware of their obligations to abide to all aspects of data regulations and particularly in respect of confidentiality and safe keeping. I be will required to complete a post-holiday questionnaire to support future fundraising.

Please confirm your consent to the above terms here:

Yes (Please tick)

Would you like to be added to our mailing list?

Yes

No

Signed

Date

Carer Holiday Grants Application Form

Details of the Carer

Please confirm the following:

Full Details of the person with disabilities

Eligibility

Holiday

Financial

Declaration