Application for Self-Find Grant

Child's Name (please complete a separate form for each child)*

First NameLast Name

Child's Address*

Street Address

Street Address Line 2

Towncounty

post code

Child's Date of Birth*

Name of Parent / Guardian*

Title / 1st name/ last name

Parent's address if different from above

Parent's email*

example@example.com

Parent's phone number*

Brief description of child's special needs and the circumstances which give rise to your request for care*

Brief explanation of the kind of respite care you require *

Which school does your child attend?*

Please explain what help you currently receive with you child*

You are applying for a Self-Find grant which means that it is your responsibility to find a suitably qualified carer or service provider and be responsible for the appropriateness of the service they provide.

In the box below please tell us about the carer you have chosen. We need to know their name, contact details, registration number and the organisation with which they are registered or details of their certification. They need to hold public liability insurance. Please note we can only fund suitably qualified carers and service providers and cannot fund family members. The carer or service provider must be able to provide CHAT with an invoice when the care or activity has been delivered which CHAT will settle direct.

Details of the carer or service provider*

Please explain the total funding you are seeking*

Tell us the number and cost of each session. Note: CHAT's grants are variable. The average is currently around £300

If CHAT is able to assist, you will receive a formal offer letter or email requiring your written acceptance. You will need to get this letter countersigned by someone who knows the child and can vouch for the suitability of your application, this can be a Teacher, Doctor, District Nurse, Social Worker, Charity worker or Religious leader.

Yes I can print an emailed letterI don't own a printer so please post a letter to me

If this grant is approved please explain the difference this will make to you and what it will enable you to do while the care is provided.*

Data Protection and Privacy

CHAT children’s respite requires the information requested on this form for the sole purpose of enabling us to decide whether a grant for respite care or activity can be provided for you. Without the information we are unable to process any application. The information on the form will not be transferred in any way to a third party unless we are required to do so by law and will be stored securely.

By applying for a grant you are giving CHAT children’s respite permission for your information to be held and used as described above.

A copy of our Privacy Notice can be provided on request.

Parent / Guardian’s Declaration

In submitting this form:

· I confirm that I have read and understood CHAT children’s respite’s declaration regarding the retention and use of my personal information contained within this form and hereby give them my permission to retain it in the ways and for the uses described.

· I confirm that I have disclosed all relevant information and that you may contact me by letter, phone or email about this application.

Date*

Is there anything else you want to tell us?