Time for Carers Fund – Application Form

To apply for a Time for Carers grant please read the guidance notes and complete the form fully. Without accurate and complete information we may not be able to process your application. Guidance notes are indicated in an ‘orange’ font colour.

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)

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

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?
Every dayMost daysOccasionallyNever

Do you help with washing and/or dressing?
Every dayMost daysOccasionallyNever

Do you help with medication and/or other medical tasks or therapies?
Every dayMost daysOccasionallyNever

Do you help with toileting and continence issues?
Every dayMost daysOccasionallyNever

Do you have to supervise, support and/or prompt the person you care for?
Every dayMost daysOccasionallyNever

Do you provide emotional support and encouragement?
Every dayMost daysOccasionallyNever

Do you help with the following tasks?

TransportShoppingLooking after the homeAttending appointmentsSupport with finances

Use this space to write about any other help or support you provide that you would like to tell us about.

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)

Tick to tell us what you will spend the grant on. Tick all the boxes that apply.

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

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

Please note: if you would like the grant to go on holiday or to have a weekend break, your application form will not be processed until Government Guidance allows such activities.

Complementary therapies e.g. massage, reflexology, relaxation session

Training course fees, books or equipment e.g. adult education course, evening class, leisure course

Health and well-being sessions e.g. gym membership, exercise class

Day trips e.g. coach trip, visiting friends or family

Social outings e.g. concert, theatre, cinema, restaurant, coffee with friends/family

Driving lessons e.g. lessons, theory test, provisional licence

Purchase of items for a leisure break e.g. a tent or a bike

A laptop or tablet/iPad/Smartphone (not a phone contract/bill)

Items for hobbies e.g. art and crafts materials, gardening items, exercise equipment

Please use this space to tell us how you think you will benefit from the grant (e.g. time for myself, having a break, recharge batteries, improve health etc)

Section 6: For completion by the Agent supporting this application

Your application must be supported by an Agent who can verify your caring role before sending this form back to us. During the current lockdown, we can accept an email or letter from your agent. Please visit this page for email and address details.

If your supporting agent is not with you as you fill in this form - you may contact them and have them fill in a separate form on your behalf for this section. Please provide your supporting agent with this link: https://www.carersleeds.org.uk/t4c-agents/ and ask them to fill it in for you.

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.

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

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.

Section 7: 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 7 - Applicant’s declaration and consent'.

Tick the box to indicate that you have read 'Section 7' and agree to the above statements. (required)

Section 8: Information, advice and support for carers

Carers Leeds offers a wide range of confidential information, advice and support for adult and parent carers in Leeds. If you would like to talk to one of the 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 two months

Section 9: 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.

Note: If you select 'Bank Transfer' a member of Carers Leeds Staff will contact you to arrange payment direct to your bank account. Bank details will only be obtained by Carers Leeds after your application has been approved at the Time for Carers Panel.

Section 10: Monitoring data (This section is optional)

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.