Time to Live Application Form

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.

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 be as detailed as possible.

Please provide details about the type of care you provide (help with personal care, help with shopping, domestic tasks, ensuring medication is taken, etc.). Please be as detailed as possible.

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?

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.

Example 1

"I would like to go to Aberdeen on the ferry to see family. I would like to do this in November due to a family event/birthday and the cared for person will not be coming. I would arrange for family to look after the cared for person while I am away"

"The cost of the break is broken down as follows:

£300 for return travel on the ferry
£300 for a hotel for two nights"

Example 2

"I would like to go for a massage a month at Well-being Reset Therapies. This would be time for myself, help my mental well-being by relaxing and and a break away from my caring responsibilities."

"The cost of the break is £60 per massge, therefore 6 months of massages would be £300."

Please let us know exactly what you are looking to use the grant for, the most approximate cost, how much of the grant you are looking to receive (up to a maximum of £300) and whether you will be having the break alone or with others.

These are only examples to guide you to fill in the application, please see the eligibility criteria for examples of other breaks which could be used to give you a break from your caring responsibilities.

Please describe in detail what you would like to do, when the break will take place, 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?).

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 be as detailed as possible to ensure your application is seen by the panel as soon as possible.

Please provide a quotation or screenshot if this is possible:

How much funding are you looking for? (Up to a maximum of £300)

If you are not applying for the full cost of the break or item(s), how will you make up the shortfall?

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?

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

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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