Creative Breaks Fund

Application Form 2013

1) Tell us a bit about you:

Full name
Address
Home telephone number
Mobile phone number
Email address

2) Tell us what you would like to get out of your short break

Please tick/select all the boxes that apply

To rest, relax and recharge my batteries

Get away from the house and daily routines

Protect my health and wellbeing

To spend time with my family

To catch up with things at home

To pursue opportunities for leisure, community, cultural activities, e.g. time for my hobbies/interest, being involved in my community, doing something new, seeing new places

Is there anything else?

3) Would you prefer to have your Short Break with the person you care for, with others or on your own?

I would want to have my short break with the person (people) I care for

I would want to have my short break separately

Other family members /friends would go with me on my short break

4) Would you want to stay at home or go away?

6) Have you an idea of what you want to do or where you want to go on your short break

7) Ideally, how long would you like your short break to be?

8) If you would rather have a regular break, how often would you like the breaks to be?

9) Is there anything you need to help you get the most out of your short break?

10) Is there anything that might prevent you getting the most out of your short break?

11)In order to report to the funders we will be required to give examples of the breaks that carers took, do you agree to Sense Scotland contacting you about your break?

Please indicate Yes No

12. Agreement

You must sign here in order for us to be able to process your application

I______have read, understood and agree to the terms and conditions and data protection statement. (you will find these in the terms and conditions leaflet enclosed with this form)

Carers signature
Date
If someone supported you to complete this application can you ask them to sign below
Supporters signature
Date