an older adult with a young carer laughing

Overview

Holiday Lodge Application Form

About You

Title (required)

If you selected "Other" title, please let us know your title

First name (required)

Last name (required)

Address (required)

Town (required)

Postcode (required)

Home Telephone (required)

Mobile Telephone

1. Do you have family or friends who are available to give you time off from caring most of the time when you need it? (required)

2. Are you caring for more than 20 hours a week? (required)

3. Do you live in the same household as the person you are caring for? (required)

4. Is the person you care for in full time education, voluntary or paid employment, and / or do they attend a day centre or engage in a community activity for periods of 6 hours or more in a single day most weeks? (required)

5. Have you been able to have a break from your caring responsibilities for a period of seven days or more in the last year? (required)

6. Have you been looking after you cared for person for more than 8 years? (required)

7. Have your caring responsibilities substantially reduced the amount of time you spend doing social or leisure activities? (required)

8. Would you consider that your physical health is generally good? (required)

9. Would you consider that your mental / emotional health is generally good? (required)

10. Are you currently attending regular appointments with a health care professional? (For example, this could be a G.P., consultant, nurse, Physiotherapist, Occupational Therapist or other health professional) (required)

11. Are you frequently able to switch off from all your caring responsibilities? (required)

12. Are you over 65? (required)

13. Are you in receipt of any means tested benefit and/or in receipt of the highest rate Attendance Allowance, or enhanced rate for daily living of the Personal Independence Payment? (required)

14. Does the person you care for usually have challenging or unpredictable needs or behaviour? (required)

Please tell us how many people you provide care for:? (required)

Terms and Conditions

I provide unpaid care to another person due to their age, physical or mental illness, learning disability or addiction (you may still receive Carers Allowance).
I agree to answer the questions honestly
I agree to be subject to a check by the Carers Support Service regarding the information I give.

Agreement to Terms and Conditions (required)

Further Information

The following questions do not form part of the short breaks calculation for your award, but they will help us understand the profile of the people who apply to use the lodge.

If you go to the lodge, will it be: (required)

Have you had a Direct Payment for a break in the last 12 months? (required)

Are you a member of the Carers Information Service? (required)

If you are not a member of the Carers Information Service would you like us to send you a joining form? (You can also join online by visiting www.crispweb.org/joincis) (required)

What best describes the condition of the person you care for? (required)

If a different condition, please let us know

Please tell us how you found out about the holiday lodge.

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