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Time for Carers Fund – Application Form

To apply for a Time for Carers grant please ensure you have read these guidance notes and complete the form fully. Without accurate and complete information we may not be able to process your application. Helpful tips for completing the form are indicated in orange.

If you require any support completing this application a member of our team can help you by calling 0113 246 8338.

    Section 1: Communication and language support

    We can provide a range of services to support carers who have additional communication needs, because English is not their first language, or because they have a disability.

    Section 2: Information about you (the carer)

    About you (the carer):

     

    Your address:

     

    Section 3: Information about the person with care needs

    The person with care needs must live in the Leeds area

    Does the person with care needs live with you? (required)

    YesNo

    Does the person with care needs live in Leeds? (required)

    YesNo

    Section 4: Information about the support you provide

    In what ways do you/did you help the person with care needs? Tick all the boxes that apply.

    Do you prepare meals and/or help with eating and drinking? (required)

    Every dayMost daysOccasionallyNever

    Do you help with washing and/or dressing? (required)

    Every dayMost daysOccasionallyNever

    Do you help with medication and/or other medical tasks or therapies? (required)

    Every dayMost daysOccasionallyNever

    Do you help with toileting and continence issues? (required)

    Every dayMost daysOccasionallyNever

    Do you have to supervise, support and/or prompt the person you care for? (required)

    Every dayMost daysOccasionallyNever

    Do you provide emotional support and encouragement?(required)

    Every dayMost daysOccasionallyNever

    Do you help with the following tasks? (required)

    TransportShoppingLooking after the homeAttending appointmentsSupport with finances

    Please use this space to explain your caring role. Tell us what support you provide to the person you care for and the impact this has on you. (required)

    Section 5: Information about your application

    A Time for Carers grant cannot be used to pay for a holiday, activity, outing or item which you have already purchased.

    At busy times, it can take up to 5 months from the date we receive your application until the date you hear the outcome. Only book a break or purchase an item when you receive the money into your bank or by cheque.

    How much are you applying for? (Maximum is £250) (required)

    The grant must specifically be used for the following:

    • A holiday (with or without the person with care needs)

    • A weekend break (with or without the person with care needs)

    • Day trips

      • Coach trips, train journeys, trips to the coast, theme parks, visiting friends or family (the grant can be used for petrol however, exclusively to form part of the break)

    • Wellbeing & complementary therapies:

      • Spa break, facial, massage, acupuncture, reflexology, hairdressing, manicure, podiatry, and chiropody treatment.

      • Gym membership, exercise classes such as yoga, swimming

    • Course fees

      • Books or equipment required, evening classes for leisure or further education

    • Social outings

      • Concert, theatre, cinema, bowling, meal out/coffee with friends/family

    • Driving lessons

      • Lessons, theory test, provisional licence

    • Purchase of items for a hobby/interest

      • Watercolour paints, gardening, books, puzzles, walking (boots, waterproofs), running (shoes, clothing specific to running), cycling (a bike or a helmet), camping (a tent)

    • Technology Equipment

      • Laptop / tablet / iPad (Not a mobile phone or contract)

    A Time for Carers grant cannot be used to pay for a break/holiday, activity, outing or item which you have already purchased. The grant must not be used for ordinary living costs i.e. supermarket food, white goods (fridges etc.), bills, travel expenses.

    Please use this space to specify how you will use the Time for Carers Grant should your application be successful, and tell us what difference this will make to you as a carer. (required)

    Section 6: Applicant’s declaration and consent

    • I confirm that I have read and understood the guidance notes and criteria for completing a Time for Carers application

    • I confirm that the information on this application form is correct

    • I consent to my personal details included on this application form being shared with Leeds City Council for their reporting purposes

    • I understand that Leeds City Council may contact me about services for carers

    • I consent to Carers Leeds processing and storing my personal information in electronic and manual format

    By submitting this form - you indicate that you have read and agree to the above statement in 'Section 6 - Applicant’s declaration and consent'.

    Tick the box to indicate that you have read 'Section 6' and agree to the above statements.(required)

    Section 7: Information, advice and support for carers

    Carers Leeds offers confidential one to one or group support to help carers keep on caring. We are based in the centre of Leeds, and also work in local communities, over the phone and online. If you would like to be called by one of our carer support workers, please tick one of the boxes below or contact our Carers Advice Line by phone 0113 380 4300 or by email advice@carersleeds.org.uk.

    Carers Leeds also produces a free newsletter every month

    You can sign up to receive our newsletter by subscribing here: https://www.carersleeds.org.uk/publications/newsletter/

    Section 8: Payment details

    If your application is successful you can choose either to receive a cheque or we can pay the grant straight into your bank account. Please tell us how you would prefer to receive the grant:

    If your application is successful a member of Carers Leeds staff will contact you for payment details.

    Section 9: Monitoring data

    We collect this information to make sure our services are reaching all carers. The information you give us in this section will not be linked to your name or address.

    What is your ethnicity? Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box.

     

     

    Section 10: For completion by a professional supporting this application

    Your application MUST be supported by a professional who is involved with you as the carer or the person with care needs in a professional capacity. The professional will need to support your application by verifying your caring role before we can process your application.

    Examples include:

    • Occupational Therapist

    • Physio Therapist

    • Social Worker

    • Doctor

    • Adult Social Carer Wellbeing Worker

    • Social Prescriber

    • Mental Health Support Worker

    • Neighbourhood Network

    • Teacher / Tutor / Special Education Needs and Disability Worker

    • Line Manager

    The professional cannot be a relative, friend or work colleague. If you are in any difficulty obtaining a professional statement, or do not receive professional support, please contact us on 0113 246 8338. We may be able to support your application, but we would need to speak with you about your caring role.

    After submitting your application, please ask your supporting professional to complete the Professional Statement online here.

    Tick this box to confirm that you understand that: (required)

    • Your application will not be processed until we have received the additional information from your supporting professional.

    • That Carers Leeds reserve the right to contact the supporting agent to verify the information on this application form is correct.