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.

Details of the person with the disabilities

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

Contact Details (if different from the applicant)

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

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, housing, PIP/DLA and wages etc? (We include income for ALL those in the home)

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

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

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

If yes, how many other family members with a disability are going on the holiday?

Have you received a grant from 3H before?

What year did you receive the grant? (Our criteria states that we have a 2-year gap between awarding grants)

What year did you last have a holiday?

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

Note: If the person with the disability is NOT going on the holiday, we will not be able to fund a holiday grant however we may be able to award you a carer grant. Please apply for a carer grant via the carer holiday grant application form.

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.

Do you use a wheelchair or mobility aid?

Please provide more information on how the disability affects everyday life, including any exceptional circumstances (If applicable) and why a holiday would be of benefit.

Holiday

Note: Proposed Holiday - Grants are 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 only. We will NOT pay grants directly to applicants.

Please confirm the holiday will be taken in the UK.

Month of proposed holiday if known. Must be for the current year.

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

Name, address and relationship to the person with the disability of each adult.

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

Name, address and relationship to the person with the disability of each child.

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)

Financial

Note: Low income threshold information: If your TOTAL ANNUAL HOUSEHOLD income is less than £35,000 and you are in receipt of means tested benefits, you may be eligible to apply for a grant. We include housing, PIP and DLA in this figure. Please 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?

Child Tax Credits

Per week or month?

Jobseeker's Allowance

Per week or month?

State Pension

Per week or month?

Pension Credit

Per week or month?

Universal Credit

Per week or month?

Housing Benefit (If not already included in your UC figure)

Per week or month?

Is the housing benefit paid directly to your landlord?

Full or Part Time Work

Per week or month?

Disability Living Allowance/PIP (You must be receiving this benefit)

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 eg SSP - Statutory Sick Pay, Attendance Allowance.

Per week or month?

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

Declaration

How many adults are living in your household? (Income evidence will be required for all)

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

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

Yes

No

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

Yes

No

Note: If we are able to proceed, evidence of all of your benefits will be required, a recent copy of 1 months bank statement for all adults living in the household. Medical evidence of the diagnosed disabilities will also be required. Note: 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 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. We will be required to complete a post-holiday questionnaire to support future fundraising and promotion.

Data Protection

Yes (Please tick)

Signed

Date

Would you like to be added to our mailing list?

Yes

No

Holiday Grants Application Form

Introduction

Details of the person with the disabilities

Contact Details (if different from the applicant)

Eligibility

Holiday

Financial

Declaration