Time to Live Application Form

Time To Live Grant Application Form

Remember that Time to Live funds are not just for holidays or trips away from home – see the Guidance Notes for examples of the kind of things carers have used the funding for in the past. The main priority is that carers can access the type of break which is most beneficial for them and we wish to be flexible. The short break, item or equipment must not already have taken place or been purchased prior to your application being approved. If you are not clear at this stage what break would be best, please contact us before going any further. We cannot process applications which do not show a clear plan for the break.
How we will use your information

The information you provide in this application will be used to assess your eligibility for the break. We may also use anonymised information for monitoring, reporting, and service improvement purposes. Your personal information will be stored securely and handled in accordance with data protection legislation. If your application is successful, we will contact you after your break to ask you to complete an evaluation form about your experience and the outcomes achieved.
Carer's Details (you)

Please provide the following information.
Name

First NameLast Name
Address
Postcode
Email
example@example.com
Phone Number (Main)
Alternative Contact Number (e.g. home phone)
Date of Birth
Gender
Ethnicity
Have you received Time to Live funding in the past 12 months?
Would you like to be added to our Carers Register? If you join the register, we may send you information, updates, and resources that could be useful to you in your caring role.
Information about the caring situation

All applicants to the Time to Live fund must be unpaid carers of children, adults or older people with care and support needs. The questions in this section are designed to give the panel members a picture of the needs of the cared-for person, the level of support provided by the carer and the impact this has on you as a carer.
Please tell us the name of the person you are caring for:
Please tell us the date of birth of the person receiving care:
Address of the person you are caring for:
What is your relationship to the person you care for:
Please name the health condition(s) of the cared for person (e.g. Dementia, Autism)
Please provide details about the type of care you provide (help with personal care, help with shopping, domestic tasks, etc.)
How does the care you provide affect you? Does the cared for person live with you? (e.g. mental wellbeing is under strain, no free time for social and/or leisure, relationships are strained)
How long have you been providing care for this person?
Does the cared for person live with you? Yes/ No If no, please state where they live (e.g. alone, in sheltered accommodation, or other (please state) and whether they receive any paid care and support in their home.
On average, how many hours a week do you spend caring or providing support?
Does anyone else help with the caring?
Help with the caring task

The questions in this section are designed to give the panel members information on any support you (the carer) currently receive. Please answer as fully as possible.
What support with the day-to-day tasks do you get at the moment?(domestic support, care at home visits or other family members support etc.)
Please describe any formal or informal services that provide you with a break from your caring role - (e.g. day care, private carer, or support from organisations such as the Shetland Care Attendant Scheme or family members). Include who provides the service/ break and how often you access it.
About the short break for the carer

Please give us as much information as you can about the planned break and how you would like to use the funding you have applied for. If you are not clear at this stage what break would be best, please contact us before going any further. We cannot process applications which do not show a clear plan for the break. ** N.B. Applications for travel abroad will not be supported unless there are exceptional circumstances **
Describe what you would like to do, when, and who will take part. Will your break be with the cared for person or will you take part in solo activities or be accompanied by someone else (please tell us who and their relationship to the cared for person/ you?)
Cost of the break

Please enclose (where possible) with the application, a quotation which shows the likely costs of your break e.g. a quote from a travel agent/internet service; price list for alternative therapies; note of fees for service; quotes for equipment etc. Your application will not be approved if any deposit or payment towards your proposed break has been made before you have been contacted regarding the outcome of your application. If you are unsure about how to cost your break, please contact us for help.
What is the estimated total cost of the break/ item/ equipment?
Please provide a breakdown of the total cost and how this was worked out (e.g. Travel for 2 adults & 2 children £300, 3 bedroom self catering apartment 2 nights £400 or Magazine subscription 1 year £60 etc.):
Please provide a quotation or screenshot if this is possible:

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How much funding are you looking for?
If you are not applying for the full cost of the break or item(s), how will you make up the shortfall?
Break Outcomes

These questions are about the difference that taking a break will make to your life and wellbeing.We have identified three main areas that we would like you to focus on. There is also an additional section where you can tell us about any other benefits you think the break may provide. Your break does not need to achieve all of the outcomes listed. Please select the outcome or outcomes that are most relevant to you and your situation.After your break, you will be asked to complete an evaluation form to tell us about the impact it has had in relation to the outcomes you selected.
Who will benefit from this break? Just me/ Me and one or more carers in the household/ Someone else (please tell us who), if more than one carer will benefit please briefly tell us who they are and their relationship to the cared for person/ detail any cared for person that may benefit from this application
What difference will the break make to your mental health and wellbeing (reduce stress, anxiety etc.)?
What difference will this break make to your ability to take part in social and/or leisure activities?
What difference will the break make to your relationship with the person you care for, and others?
What difference will the break make to your schoolwork/homework and general education? (if applicable)
Additional option - How will the break support you, the carer in your role?
Referee

Please provide contact details for a professional who can confirm your caring role (e.g. social worker, district nurse, school staff member, voluntary sector worker, or other healthcare professional). We may use these details to verify your caring status if required.
Full name of the professional
Job role (e.g. social worker, district nurse)
Organisation/ Service Name
Contact Details (email/ telephone number)
example@example.com
Was this application completed with support from another person or organisation?
If yes, please provide the name of the person and organisation
Signature & Acceptance

Payment Details: We do not collect or retain bank account details as part of the application process and will only request them once an application has been approved.
Signature
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Time To Live Grant Application Form

How we will use your information

Carer's Details (you)

Information about the caring situation

Help with the caring task

About the short break for the carer

Cost of the break

Break Outcomes

Referee

Signature & Acceptance

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