APPLICATION FORM FOR TIME TO LIVE SHORT BREAK GRANT/RESPITALITY BREAK

Caring for someone can happen very suddenly, sometimes overnight, or you may find yourself doing more and more over many months and years. Although rewarding, looking after someone can affect your physical and emotional wellbeing and impact on you financially and socially.

A carer is generally defined as a person of any age who provides unpaid help and support to a relative, friend or neighbour who cannot manage to live independently without that person's help.

Short Break Grant

Applications will be assessed at our regular panel meetings throughout the year. You will be notified of the outcome within three weeks of the panel meeting date. To view our panel meeting dates, please visit: https://www.shetlandcarers.org/support/breaks/short

If your application is successful, we can either transfer money into your bank account or send out a cheque to you - whichever you prefer.

We will then register you with our confidential Shetland Carers database. This enables us to record that you are a carer and send you any new carer information.

As part of the conditions for the grant, you will need to send us receipts for your Short Break. We also require that you fill in an evaluation form telling us about your Short Break. This helps us to monitor the success and take-up of the project and make improvements where necessary.

Respitality Break

Applications will aim to be assessed as they are submitted and you will be notified of the outcome within three weeks.

If your application is successful, we will then liaise with you regarding your break which may involve passing your contact details on to the donor so that your break can be booked.

We will then register you with our confidential Shetland Carers database. This enables us to record that you are a carer and send you any new carer information.

After your Respitality Break we would ask you to return the completed postcard from your pack so that this can be passed on to the donor on your behalf. We will also require you to complete an evaluation form.

This form should be completed by the carer, young carer or any person supporting the carer.

**I AM APPLYING FOR A BREAK. PLEASE ADD ME TO THE CARERS' DATABASE**

Please provide the following information about the CARER:

First name and surname

Preferred name

Address

Postcode

Phone Number

Area CodePhone Number

Mobile

Email

Date of Birth

If you prefer not to share your age please tick this box

Gender

Ethnicity

Social Locality (Local Health/GP Centre)

Please provide details about the type of care you provide (help with personal care, helping with shopping, domestic tasks etc)

How long have you provided care for this person?

On average, how many hours a day do you provide care?

On average, how many hours a week do you spend caring or providing support?

Anything else you want to tell us in relation to this?

Is your caring role impacting on you?

NoneSomeLots

If you indicated SOME or LOTS above, please detail how you consider your caring role has impacted on you. Please choose all that apply.

Do you have any other family members to support you? YES/NO (please provide details)

Do you feel you are experiencing social isolation? YES/NO (If yes, please provide details)

Do you have any health and wellbeing conditions of your own? (If yes, please provide details)

If you are not currently registered with Shetland Carers, please provide details of someone who can confirm your caring role e.g. family member / health professional / social worker. Please provide their NAME, TELEPHONE NUMBER AND RELATIONSHIP TO YOU.

How did you find out about the Respitality Break / Short Break Grant Scheme for carers?

Information about the caring situation

This section relates to the CARED FOR PERSON. Please choose the correct statement which applies:

**You MUST CHOOSE one of the statements below**

I DO NOT HAVE CONSENT FROM THE CARED FOR PERSON / POWER OF ATTORNEY SO CANNOT COMPLETE THIS SECTION - PLEASE NOTE THAT, AS A MINIMUM, WE REQUIRE THE NAME OF THE CARED FOR PERSONI AM A YOUNG CARER TO A CHILD UNDER 16. I HAVE OBTAINED CONSENT FROM THEIR LEGAL PARENT/GUARDIAN FOR THEIR INFORMATION TO BE SHARED BELOWI AM THE CARER OR, AND LEGAL PARENT/GUARDIAN TO, A CHILD UNDER 16. I GIVE CONSENT FOR THEIR INFORMATION TO BE SHARED BELOWI HAVE OBTAINED CONSENT FROM THE CARED FOR PERSON (OVER 16 YEARS) TO SHARE THEIR INFORMATION BELOWTHE CARED FOR PERSON (OVER 16 YEARS) DOES NOT HAVE CAPACITY TO CONSENT. I AM THEIR POWER OF ATTORNEY AND GIVE CONSENT FOR THEIR INFORMATION TO BE SHARED BELOWTHE CARED FOR PERSON (OVER 16 YEARS) DOES NOT HAVE CAPACITY TO CONSENT. I HAVE OBTAINED CONSENT FROM THEIR POWER OF ATTORNEY FOR THEIR INFORMATION TO BE SHARED BELOW

Please provide the following information about the CARED FOR PERSON:

**As a minimum, we require the NAME of the cared for person**

First name and surname

Age Group

0-17 child18-64 adult64+ older adult

Does the cared for person live with you?

Gender

Ethnicity

What is the illness/condition/disability of the person you care for? Please choose all that apply.

What is your relationship to the cared for person?

I am the child/grandchild of the cared for personI am the parent/grandparent of the cared for personI am the spouse/partner of the cared for personI am a relative (any other relationship) of the cared for personI am a friend/neighbour of the cared for person

To help us understand the extent of your caring role, please detail any support YOU are receiving from social services / other third sector organisations (if any). If none, please write NONE. (You can tell us about support for your cared for person below)

To help us understand the extent of your caring role, please detail any support YOUR CARED FOR PERSON is receiving from social services / other third sector organisations (if any). If none, please write NONE.

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If you are applying for a Short Break grant ONLY, please continue below.

If you are applying for BOTH a Short Break grant and Respitality break, please continue below.

If you are applying for a Respitality break ONLY, please scroll down to the section headed ***APPLYING FOR A RESPITALITY BREAK***

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Have you received a Short Break grant from Take a Break Scotland OR any other organisation (apart from Shetland Carers) in the past 12 months? Please provide details:

Have you received a Short Break grant from us before? If yes, please provide the date:

Please provide details of how you would use a Short Break grant or an SRT More4Life monthly membership including a costing for your Short Break(s) e.g. one overnight stay with dinner and breakfast included = £150 or four reflexology sessions x £30 = £120 - should you wish to apply for this option. A Short Break grant awarded will reflect a contribution towards the break, subject to a maximum amount of £300.

An SRT More4Life monthly membership is £31.99.

**Please note, before you specify that you want to apply for an SRT More4Life monthly membership, you may wish to explore if you qualify for SRT's 'Access to Leisure' concession scheme. If you do qualify for Access to Leisure, you will pay just £1 for activities included in More4Life and you don't need to pay a recurring membership fee.

You are eligible if you receive certain benefits including carers allowance.

Please visit https://www.srt.org.uk/pricing/more4life for more information or telephone: 01595 741000**

Break proposal

Costing

Please explain how the break would benefit you

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If you are NOT applying for a Respitality Break, please now scroll down to complete the final section headed ***FURTHER INFORMATION AND DATA PROTECTION***

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***APPLYING FOR A RESPITALITY BREAK***

Have you received a Respitality Break from us before? If yes, please provide the date:

Have you received a grant/break from us OR any other organisation in the past 12 months? Please provide details:

Please rank in order from 1 to 9 your Respitality Break preference, with 1 being your most favoured and 9 your least favoured break. Please use all numbers from 1 to 9 and each number should only be used once.

	Number (1-9)
Overnight Stay
Self Catering Stay
Dining
Visitor Attraction
Tickets
Sports Break
Wellbeing Therapies e.g. yoga, pilates, reflexology
Pamper treatments e.g. hair, nails, massage
A class or learning experience e.g. arts and crafts
Other (please detail below)

Other:

Please tell us how a break, awarded through the Respitality Scheme, would benefit you.

Emergency Contact Details

I consent to Shetland Carers passing on my Emergency Contact Details to the Gift Provider.

Who would you like Shetland Carers, or your Gift Provider, to contact in the event of an emergency during your break? (Must be someone not accompanying you on your break)

Name:

Relationship to you:

Contact Telephone:

Please let us know if you know of any potential Respitality Gift Providers we could approach:

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MEDIA CONSENT - ONLY COMPLETE THIS PART IF YOU ARE APPLYING FOR A RESPITALITY BREAK

Telling others about the real difference Respitality makes to people like you is essential to the growth and impact of the service, so that even more unpaid carers can benefit. Please let us know if you are happy or not to share your story or any quotes provided by completing the checklist below.

Any information you provide may be used to promote Respitality through a variety of channels including media publications and websites, social media and websites promoting the work of the initiative, as well as partner agencies involved.

I agree to: (please choose all that apply)

The Respitality team contacting me for more informationAny quote I give being used in Respitality, Shared Care Scotland or Shetland Carers reports, promotions or articlesMy case study being shared with media representativesBeing named in connection with any of those activities I have agreed to above

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***FURTHER INFORMATION AND DATA PROTECTION***

Shetland Carers have a legal requirement to submit a Carers Census Return to Scottish Government on a bi-annual basis. All data provided is anonymised. The information which we request in this form is in line with this.

Here at Shetland Carers/Voluntary Action Shetland (VAS) we take your privacy seriously and will only use your personal information to administer your account through our database, to provide the products and services you have requested from us and from time to time to share information relating to the service we provide.

Where appropriate, and with your consent, we will liaise with a range of other partners to support you in your caring role.

Shetland Carers aligns with the Shetland Child and Adult Protection Procedures and we may need to pass on information where it is deemed necessary to do so.

Please indicate your preferred method(s) of communication from Shetland Carers:

PostEmailTelephone

Throughout the year we would like to send you our newsletter to provide information relating to our service. Please tick if you agree to us providing you with a copy of our newsletter. You can unsubscribe from receiving our newsletter at any time.

I agree

I HAVE READ THE INFORMATION ABOVE AND I CAN CONFIRM THE DETAILS PROVIDED ARE CORRECT.

I HAVE READ AND UNDERSTOOD AND AGREE TO THE DATA SHARING NOTIFICATION.

I AM EITHER:

A YOUNG CARER TO A CHILD UNDER 16 AND THEIR LEGAL PARENT/GUARDIAN HAS GIVEN CONSENT FOR THEIR INFORMATION TO BE SHARED OR

THE LEGAL PARENT/GUARDIAN OF A CHILD UNDER 16 AND GIVE CONSENT FOR THEIR INFORMATION TO BE SHARED OR

I HAVE OBTAINED CONSENT FROM THE CARED FOR PERSON (OVER 16 YEARS) TO SHARE THEIR INFORMATION OR

THE CARED FOR PERSON (OVER 16 YEARS) DOES NOT HAVE CAPACITY TO CONSENT. I AM THEIR POWER OF ATTORNEY AND GIVE CONSENT FOR THEIR INFORMATION TO BE SHARED OR

THE CARED FOR PERSON (OVER 16 YEARS) DOES NOT HAVE CAPACITY TO CONSENT. I HAVE OBTAINED CONSENT FROM THEIR POWER OF ATTORNEY FOR THEIR INFORMATION TO BE SHARED.

Signature

Date

Name (Please print)