Holiday Grant Form - The 3H Foundation

How did you hear about us?

Introduction

Is the person with a disability an Adult or Child?

Please select where you live/ applicable category.

Section A: Personal Details

Details of the person with the disability

Title

First Name

Last Name

Age

Date of Birth

Address Line 1

Address Line 2 (optional)

Town

County

Post Code

Home Telephone Number

Mobile Telephone Number

Email Address

Details of contact if different to above

Title

First Name

LastName

Relationship to the person with the disability

Address Line 1

Address Line 2 (optional)

Post Code

Town

County

Home Telephone Number

Mobile Telephone Number

Email Address

How many people live in your household?

Adults

Adults in full time education

Children

Please list people who are living with you

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Section B: Criteria/Eligibility

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

Are you on a means tested benefit (Universal Credit or Pension Credit) with no other unexplained income?

Do you have £3,000 or more in combined savings in any bank or building society account.

Is the applicant in receipt of DLA/PIP?

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

THIS 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 12 months or more. e.g. a breathing condition that develops as a result of a lung infection.

Are there any additional family members going on the holiday with a disability?

If YES, how many other family members with a disability?

Have you received a holiday or carer grant from The 3H Foundation before?

If YES, when was this? (i.e. the year)(Our criteria states that we have a 2-year gap between awarding grants)

Have you applied for any other holiday grant? If YES, please give details below.

Please confirm the person WITH the disability will be going on the holiday.

What year did you last have a holiday/break of one night away or more? (i.e. the year)

Where does the person with disabilities live? (At home, Nursing home, Residential care home, Other)

Please list the main diagnosed disabilities. Evidence will be required at a later date. Undiagnosed disabilities will not be accepted.

Are you a wheelchair user?

Disability evidence will be requested at the next stage, such as a letter from a doctor, hospital, social worker or some other medical professional dated within the last 12 months. A copy of your patient notes is acceptable as long as it states the disability. (WE CANNOT ACCEPT DLA/PIP AS EVIDENCE BECAUSE THIS DOES NOT CONFIRM THE DISABILITY.)

SECTION C: PROPOSED HOLIDAY

Please note that grants are only for the ACCOMODATION part of a holiday and 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.

Month of proposed holiday (if known).

Total number of adults going on the holiday from your household?

Total number of children going on the holiday from your household?

Please list everyone going on holiday

Name

Address

Relationship

Name

Address

Relationship

Name

Address

Relationship

Name

Address

Relationship

Cost of the holiday (If known)

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)

Other funding applications

Social Services

Funding yourself

SECTION D: YOUR SITUATION

Please provide more information on how your disability affects your everyday life, including the main challenges you are facing at present and how a holiday grant would be of benefit to your familiy.

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 in '0'.

Universal Credit (Before deductions)

Per week or month?

Disability Living Allowance

Per week or month?

Carers Allowance

Per week or month?

Salary

Per week or month?

Employment and Support Allowance (ESA)

Per week or month?

Housing Benefit (If not already in your UC figure)

Per week or month?

State 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

Per week or month?

Please add 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 your benefits will be required such as letters from the benefit agencies and copies of 1 month's bank statements - dated within 3 months. This requirement is for all adults (18+) in your household.

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 THAT WE OFFER ARE MODEST GRANTS BETWEEN £250 and £550.

DECLARATION

I confirm the information provided in this application is true and complete and I agree to The 3H Foundation's terms and conditions. These can be found on our website or requested separately.

Agree

Disagree

I understand that providing false or misleading information may result in my application being automatically rejected.

Agree

Disagree

I understand that in order to comply with the Data Protection Act 2018 and for The 3H Foundation to administer my/our application, I/We give permission for you to keep this information on file.

Agree

Disagree

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

Agree

Disagree

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

Agree

Disagree

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 and/or comments in newsletters, leaflets, on their website and/or for reporting back purposes. (This will be in first name format only)

Agree

Disagree

Signed

Date

Would you like to be added to our mailing list?

Yes

No

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Holiday Grants Application Form

Introduction

Section A: Personal Details

Section B: Criteria/Eligibility

SECTION C: PROPOSED HOLIDAY

SECTION D: YOUR SITUATION

SECTION E: INCOME DETAILS

DECLARATION