Make Time for Me Monday

Dementia carer support group

Male carers group

Section 2: Information about the carer

About the carer:

Address:

Section 6: For completion by the Agent supporting this application

A 'Time for Carers' application must be supported by an Agent who can verify a caring role as part the application process. During the current lockdown, we will accept an email or letter from the agent. Please visit this page for email and address details.

We reserve the right to contact the Agent so that they can verify that the information on this application form is correct

Section 2: Information about the carer

About the carer:

Address:

Section 6: For completion by the Agent supporting this application

A 'Time for Carers' application must be supported by an Agent who can verify a caring role as part the application process. During the current lockdown, we will accept an email or letter from the agent. Please visit this page for email and address details.

We reserve the right to contact the Agent so that they can verify that the information on this application form is correct

Time for Carers Fund – Application Form
Agent Only Section

This form is supplementary to the ‘Time for carers fund – application form’. A ‘Time for carers’ grant application must be supported by an agent who can verify the caring role of the person applying for it. This online version has been made available to alleviate any problems that may occur in arranging a supporting verification of the carers role.

For reference, the full form that the carer submits can be found here.

There are only two sections (2 and 6). Please ensure you fill in section ‘2’ accurately so that we may match it with the full application sent in by the carer.

We may wish to contact you, the agent, in order to verify information sent to us is correct. Please provide accurate contact details.

Title:

First name (required):

Surname (required):

Email address:

Age:

GP Practice:

House Number (required):

Address Line 1 (required):

Address Line 2

City (required):

Postcode (required):

The Agent must be a health or social care professional who provides a service to the carer or person with care needs. For example, a GP or other doctor, a social worker, a nurse, an occupational therapist, a physiotherapist, home care worker, day centre worker or counselor. The Agent cannot be a relative, friend, work colleague or an employer.

Agents name (required):

Job title (required):

Telephone number (required):

Agents E-mail Address (required):

Address Line 1 (required):

Address Line 2:

City (required):

Postcode (required):

How long have you known the carer and in what capacity? (required)

As an Agent supporting a Time for Carers application you are signing to verify that, to your knowledge, details provided by the carer named on this application form are correct. You are also signing to confirm that the applicant named on this form is a carer or former carer who provides/provided necessary, unpaid care to at least one person with care needs.

« July 2020 »