Group Holidays Application Form

2026 Holidays

Holiday Date

20th - 24th July

Income

Are you in receipt of a means tested benefit or on a low income?

Yes

No

Do you have savings over £3000?

Yes

No

Guest's Details

Full Name (including title)

What is your diagnosed disability?

Male/Female

Date of Birth

Address Line 1

Address Line 2

Town

County

Postcode

Home Telephone Number

Mobile Telephone Number

Email Address

Where do you live?

How many family members/carers regularly care for you?

Next of Kin/Emergency Contact

Full Name (including title)

Relationship to guest

Address Line 1

Address Line 2

Town

County

Postcode

Home Telephone Number

Mobile Telephone Number

Email

Emergency contact if next of kin is out of the country (if applicable)

GP Details

GP Name

Telephone Number

Doctor Name

Surgery Name

Address Line 1

Address Line 2

Town

County

Postcode

Telephone Number

Consent to contact GP if needed?

Yes

No

Guest Information

Do you consider yourself to have any of the following disabilities? Please tick where appropriate.

Other Disabilities (please specify)

Please add details here for any of the above including 'other'.

Please detail any medication: names, dosage, time to be taken and anything else we should know about your medication.

Have you had the Covid vaccinations?

1 Vaccination

2 Vaccinations

3 Vaccinations and Booster

None

Support - Please refer to your existing support plan (if applicable) to answer these questions and provide as much information as possible.

Do you need help with dressing? (If so please provide details.)

Do you require support with eating and drinking? (If so please provide details and eating and drinking guidelines if possible..)

Do you require support with your personal care? (If so please provide details.)

Do you require support to take your medication? (If so please provide details.)

Do you require any support to go to the toilet? (If so please provide details)

Do you require any support with your communication? (If so please provide details such as do you require visual prompts, use of Makaton, points of reference etc.)

Do you require support with dealing with money? (If so please provide details)

Do you require support dealing with others? (If so please provide details.)

Do you require emotional support? (If so please provide details.)

Please provide details of any behaviour of concern that you may exhibit, along with guidelines/strategies for minimising risk and dealing with this behaviour.

Do you require support making decisions? (If so please provide details.)

Do you require support with road safety? (If so please provide details.)

Is there a risk you might wander off from the group when out on day trips?

Do you require support when walking? (If so please provide details.)

Do you have any issues with sleeping? (If so please provide details.)

Are you able to spend time alone in your cottage when you want to relax or do you require staff support at all times? (Staff are always on site.)

Do you have any behaviour which might put yourself at risk? (If so please provide details.)

Do you have any behaviour which might put others at risk? (If so please provide details.)

Do you have any behaviour which might cause a risk in the kitchen or bathroom? (If so please provide details.)

Do you require support when taking part in activities? (If so please provide details.)

Do you require support when travelling in vehicles? (If so please provide details.)

Do you require any support when evacuating a building in case of an emergency such as a fire? (If so please provide details.)

In order to support you throughout your activity break we need as much information from you as possible.

Where will you meet us on the first day and how will you travel there? Wood St, E17 3NU or the first activity near Nutley Edge?

Who will drop you at the pick-up point? Parent, carer, travel by yourself?

If you use a wheelchair can you transfer yourself onto a seat in a minibus or do you need a fully accessible vehicle?

Do you smoke?

Yes

No

Do you drink alcohol?

Yes

No

If no, please specify if it is through choice or medical advice?

Choice

Medical Advice

Are there any cultural considerations we should bear in mind while supporting you to enjoy your holiday? (If so please provide details.)

What dietary requirements do you have? (Please tick where appropriate)

Do you have any phobias? (If so please provide details.)

Risk Assessments

Data Protection

Under the General Data Protection Regulations (GDPR) we require your consent to collect and process your personal information. Please confirm your agreement in the boxes provided:

The information I have given in this form is correct to the best of my knowledge.

Yes

No

All your personal data shall be kept confidentially by The 3H Foundation for a time deemed necessary.

Yes

No

I give permission for The 3H Foundation to forward relevant data to the holiday partner, Outward, for holiday care assessment.

Yes

No

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

Yes

No

Would you like to be added to our mailing list?

Yes

No

Signature

Date

Allergies

What is the allergy?

What reaction does the person have? What is the severity of the reaction? What are the specific signs to look out for?

Is medical assistance required? (GP, Call 999 immediately etc)

Does emergency medication need to be administered? Please provide details and when it was last administered.

Any follow up monitoring required?

If is are more than one allergy, please give details here.

Name	Domain	Purpose	Expiry	Type
_ga	3hfund.org.uk	Google Universal Analytics long-time unique user tracking identifier.	2 years	HTTP
_gid	3hfund.org.uk	Google Universal Analytics short-time unique user tracking identifier.	1 days	HTTP

Name	Domain	Purpose	Expiry	Type
_GRECAPTCHA	www.google.com	---	6 months	---
_gat_gtag_UA_163812395_1	3hfund.org.uk	---	Session	---
_ga_LMC3VC706D	the3hfoundation.org.uk	---	2 years	---