Creative BreaksFund

September 2015 – October 2016

Application Form

(Please read ‘Criteria for use’ guidance before completing)

Those who received funding in the last year are not eligible to apply.

Local Authority:
Name (Carer):
Address:
City: / Postcode:
Telephone no(s):
Name (cared for): / Relationship to Carer:
Permission to share information/give feedback about the break and
providing receipts are requirements of receiving funding.
Please explain why you need the break:
(Please continue on a separate sheet if required)
Please detailhow you will spend the fund:
(Please continue on a separate sheet if required)
Amount of funding required: / Date(s) of proposed break:
(If helpful you can use the boxes below to work out possible costs for your break)
Accommodation: / Travel:
Meals/Refreshments: / Support costs:
Insurance: / Other:

Please turn over

We are trying to be as flexible as possible around methods of payment soplease tell us how you would prefer to receive this funding if your
application was approved (please tick one option) –

 / By cheque
 / Directly into your bank account
(Angi Inch will contact you by phone for your bank details)
 / Directly to a holiday provider
(Angi Inch will contact you to get provider details)
 / Directly to an Alzheimer Scotland service providing you with support
(Please note below which service payment should be made to)
Service Name -
Would you prefer us to contact someone else on your behalf for this application?
Name: / Contact
telephone no(s):

If you have any questions or to return applications please contact –

Angi Inch on 07976 618419. Email Or by post to -

Angi Inch, CBF, Alzheimer Scotland, 81 Oxford Street, Glasgow, G3 5EP

Completed/Referred by:
Designation:
Contact details:
Date completed:

We need to record some important information for our funders.

Please take the time to fill in the boxes below.

What age is the person with dementia?
How many nights is the break for?
Will the funding be used for equipment to help create the ‘break’?
How many carers will benefit from the break?
How many young carers (under 25) will benefit from the break?
When was the last time you had a short break?
Have you applied for short break/time to live funding before?
(If applied before please give details in the space provided below – even if not with Alzheimer Scotland) / YES/NO
Where did you hear about the Creative breaks funding?

1

CBF – Sep 201- Aug 2016