Creative Breaks 2017: Grant Application Form
About this funding
Creative Breaks is a funding programme of the Short Breaks Fund, operated by Shared Care Scotland
on behalf of National Carers Organisations and the Scottish Government.
The purpose of the Short Breaks Fund is to increase the range, availability and choice of short breaks
for carers and those they care for across Scotland.
The Creative Breaks programme provides grant funding to third sector organisations to develop and
deliver short breaks projects and services for carers of adults (aged 21 years and over), carers of
older people (aged 65 years and over), young carers (caring for children or adults), and those that
they care for.
Help with your application
Before starting your application, please read the Creative Breaks 2017 Application Guidance
carefully. You can download the guidance from our website:
http://www.sharedcarescotland.org.uk/shortbreaksfund/creativebreaks
The Short Breaks Fund team are here to help. If you have any questions about your proposed project
or the application process, please contact us on 01383 622462.
Shared Care Scotland have a number of resources to help you prepare your application:
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Easy consultation toolkit
Easy evaluation toolkit
Unit cost calculator
Sustainability guide
You can download all of these resources from our website:
http://www.sharedcarescotland.org.uk/resources
Submitting your application
To submit your application, email [email protected] putting the name of your
organisation into the email subject line. Deadline for applications is 12 noon, Friday 26 May 2017.
Please attach the following documents to your email:
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Completed application form
Detailed budget breakdown
Your organisation’s governing document or constitution
A copy of your most recent financial statement or accounts
 Please do not send any other information at this stage.
The Short Breaks Fund is operated by Shared Care Scotland on behalf of the Scottish Government
Registered Office: Unit 2, Dunfermline Business Centre, Izatt Avenue, Dunfermline, Fife KY11 3BZ
A company limited by guarantee registered in Scotland SC161033 | Registered Charity SC005315
Creative Breaks 2017: Grant Application Form
SECTION 1: APPLICATION SUMMARY
1. Organisation name
Click here to enter text.
2. Project title
Click here to enter text.
3. Main contact for application
This must be someone who works or volunteers for your organisation.
Full name
Click here to enter text.
Job title or role
Click here to enter text.
Email
Click here to enter text.
Phone
Click here to enter text.
4. Project summary
Describe your project in no more than 50 words.
Click here to enter text.
5. Partnership project
Will this project be delivered in partnership with other organisation(s)?
YES
NO
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6. Total cost of project
What is the total cost of your project (from October 2017 to September 2018) – to the nearest £1?
£ Click here to enter amount.
7. Grant requested from Creative Breaks
How much are you requesting from Creative Breaks – to the nearest £1?
£ Click here to enter amount.
8. Project location(s)
Which Local Authority Area(s) will your project take place in?
Click here to enter text.
9. Beneficiary numbers
Estimate how many carers and cared for people will benefit from your project (from October 2017 to
September 2018).
Carers
Type no.
Cared for people
Type no.
10. Hours of short breaks delivered
Estimate how many hours of short breaks your project will deliver for carers and for cared for people.
For carers
Type no.
Hours
For cared for people
Type no.
Hours
11. Short Breaks Fund grants
Has your organisation received a grant from any of the Short Breaks Fund programmes before?
YES
NO
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Creative Breaks 2017: Grant Application Form
SECTION 2: ABOUT YOUR ORGANISATION
1. Organisation name
Click here to enter text.
2. Type of organisation
Tick one option below.
Registered charity
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Other (please specify) ☐
Click here to enter text.
3. Registration numbers
Give all relevant registration number(s) below.
Charity number
Type no.
Company number
Type no.
Care Inspectorate
Type no.
4. Main address and phone number
This should be the main correspondence address and phone number for your organisation.
Address
Click here to enter text.
Town/City
Click here to enter text.
Region
Click here to enter text.
Postcode
Click here to enter text.
Phone
Click here to enter text.
5. Website and social media
Where can we find your organisation online?
Website
Click here to enter text.
Twitter
Click here to enter text.
Facebook
Click here to enter text.
Other social media
Click here to enter text.
6. Main contact for application
This must be someone who works or volunteers for your organisation.
Full name
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Job title or role
Click here to enter text.
Email
Click here to enter text.
Phone
Click here to enter text.
7. Referees
Provide details of two referees. Referees must be familiar with your organisation and the proposed
project, but not directly employed by or affiliated with you.
REFEREE 1
Full name
Click here to enter text.
Organisation
Click here to enter text.
Job title or role
Click here to enter text.
Relationship
Click here to enter text.
Email
Click here to enter text.
Phone
Click here to enter text.
REFEREE 2
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Creative Breaks 2017: Grant Application Form
Full name
Organisation
Job title or role
Relationship
Email
Phone
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
8. Project delivery partners
You only need to answer this question if you ticked ‘YES’ in Section 1, Q5.
PARTNER 1
Organisation name
Click here to enter text.
Key contact name
Click here to enter text.
Job title or role
Click here to enter text.
Email
Click here to enter text.
Phone
Click here to enter text.
PARTNER 2
Organisation name
Key contact name
Job title or role
Email
Phone
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
9. Partnership agreement(s)
You only need to answer this question if you completed Q8 above. Do you have a formal partnership
agreement in place with your project delivery partner(s)?
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YES
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NO
SECTION 3: ABOUT YOUR PROJECT
1. Project title
Click here to enter text.
2. Creative Breaks outcomes
Projects must contribute directly to the achievement of at least two of the programme outcomes.
Tick the outcomes your project will help achieve.
O1
O2
O3
Carers and the people they care for will have improved wellbeing
Carers will have more opportunities to enjoy a life outside of their caring role
Carers will feel better supported to sustain their caring role
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3. Creative Breaks priorities
Projects that directly address one or more of the following priorities will be prioritised for funding.
Tick the priority(ies) your project will address.
P1
Choice and control: projects that seek to find new, more effective ways of
increasing carers’ choice, control and confidence in accessing short breaks that
meet their needs
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Creative Breaks 2017: Grant Application Form
P2
P3
Outreach: projects that actively seek to reach less visible and under-served
carers, such as BME carers and carers from the Gypsy / Traveller communities,
carers in remote and rural areas, carers living in areas of multiple deprivation,
carers who are less likely to ask for or access support, and help them overcome
barriers to accessing short breaks
Joint-working: projects that seek to work in partnership with other agencies to
maximise the opportunities for carers to access short breaks that meet their
needs, fill gaps and reduce duplication
4. Project beneficiaries
Estimate how many people in each category will benefit from your project.
CARERS
Total number of carers
Of this total, how many are likely to be…
New to your organisation
Young carers (aged 18 or under)
Young adult carers (aged 19 to 25)
Black or ethnic minority carers
Gypsy / Traveller carers
Carers living in remote and rural areas
Carers living in areas of multiple deprivation
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
CARED FOR PEOPLE: ADULTS (aged 21-64)
Total number of cared for adults (aged 21-64)
Of this total, how many are likely to have…
Physical disability
Sensory impairment
Mental illness (excluding dementia)
Learning disability
Alcohol or substance addiction
Dementia
Autism
Long-term illness, disease or condition
Other condition / reason for needing care
CARED FOR PEOPLE: OLDER PEOPLE (aged 65+)
Total number of cared for older people (aged 65+)
Of this total, how many are likely to have…
Physical disability
Sensory impairment
Mental illness (excluding dementia)
Learning disability
Alcohol or substance addiction
Dementia
Autism
Long-term illness, disease or condition
Other condition / reason for needing care
5. Why do you want to do this project?
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Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
Type no.
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Creative Breaks 2017: Grant Application Form
Tell us how you know this activity is needed and relevant for the people taking part. Please don’t use
this section to give us general statistics about the area or people or issue. Make sure you do include
information about:
 What issue, gap or need your project will address
 How you found out about this issue, gap or need
 What information you have that shows that this issue, gap or need really matters to people
 What you’ve done to involve people in finding out about the issue, and planning the project
so that it will address the issue
Click here to enter text. Maximum 500 words.
6. What will your project do?
Tell us what your project will do. Make sure you include all the key information about:
 WHO the project is for and how you will involve them
 WHAT activities you will deliver
 WHERE and WHEN the activities will take place
 WHY this is the best approach
 HOW your project reflects the principles of the Creative Breaks programme
Click here to enter text. Maximum 500 words.
7. What will success look like?
Tell us about the difference your project will make to carers and cared for people. See page 6 of the
guidance for more information on how to complete this section.
Outcome 1
Carers and the people they care for will have improved wellbeing
What will success look like for your project in 12 months’ time?
Click here to enter text.
How will you measure success?
Click here to enter text.
What will you deliver in order to achieve this outcome?
Target 1
Click here to enter text.
Target 2
Click here to enter text.
Outcome 2
Carers will have more opportunities to enjoy a life outside of their caring role
What will success look like for your project in 12 months’ time?
Click here to enter text.
How will you measure success?
Click here to enter text.
What will you deliver in order to achieve this outcome?
Target 1
Click here to enter text.
Target 2
Click here to enter text.
Outcome 3
Carers will feel better supported to sustain their caring role
What will success look like for your project in 12 months’ time?
Click here to enter text.
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Creative Breaks 2017: Grant Application Form
How will you measure success?
Click here to enter text.
What will you deliver in order to achieve this outcome?
Target 1
Click here to enter text.
Target 2
Click here to enter text.
8. Additional outcomes
Will your project deliver any additional outcomes? Use the blank table below to give details.
Outcome
Click here to enter text.
What will success look like for your project in 12 months’ time?
Click here to enter text.
How will you measure success?
Click here to enter text.
What will you deliver in order to achieve this outcome?
Target 1
Click here to enter text.
Target 2
Click here to enter text.
9. Longer-term impacts
Tell us about the possible longer-term impacts your project may have. This could include long-lasting
benefits for carers or cared for people, influencing change in policy or practice, lasting change for
your organisation etc.
Click here to enter text. Maximum 500 words.
10. Why are you the right organisation to deliver this project?
Tell us about your organisation’s skills, expertise and experience, and any existing links with other
relevant organisations that will enable you to deliver this project. Also, tell us about any support or
development needs you have and how these will be met, and any new links or relationships you need
to develop.
Click here to enter text. Maximum 500 words.
11. Is there anything else you want us to know about the project or your organisation?
Tell us about any other documents or information that you think would strengthen your application.
Please do not send these with your application. Our assessor will request further details if required.
Click here to enter text. Maximum 500 words.
SECTION 4: FINANCE
1. How much will your project cost and how much are you requesting from Creative Breaks?
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Creative Breaks 2017: Grant Application Form
Complete the table below, telling us the total cost of your project, how much of this you are
requesting from Creative Breaks and other funding required to make up the total. Please give all
figures to the nearest £1.
Total project cost
Creative Breaks request
Other funding
Amount (£)
Enter £
Enter £
Enter £
2. Detailed project budget
You also need to provide a detailed breakdown of your budget with your application using the Excel
spreadsheet template provided. See page 7 of the guidance for more information on how to do this.
Tick below to confirm you have submitted a separate budget (as an Excel spreadsheet) with your
application.
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Separate budget completed and submitted
3. Other funding for the project
Complete the table below to tell us about other sources of funding for this project. How much have
you already secured, and from where? What is your plan for securing any remaining balance? Use
the text box beneath the table to tell us what will happen if you are unable to secure all of the
funding required.
Source of funding
Type funder’s name / income source here
Type funder’s name / income source here
Type funder’s name / income source here
Type funder’s name / income source here
Type funder’s name / income source here
Type funder’s name / income source here
TOTALS
Secured
Enter £
Enter £
Enter £
Enter £
Enter £
Enter £
Enter £
Anticipated
Enter £
Enter £
Enter £
Enter £
Enter £
Enter £
Enter £
Click here to enter text. Maximum 500 words.
4. Your current finances
Please provide figures from your latest approved annual accounts
Accounting year ending
Total income for the year
Total expenditure for the year
Surplus (+) or deficit (-) at the year-end
Total savings or reserves at the year-end
Enter date
Enter £
Enter £
Enter £
Enter £
 You must provide a copy of your most recent accounts with your application.
5. Is there anything you would like us to know about your financial position?
Use this section to give more detail about your organisation’s financial position. If you have high or
low reserves, it is important that you explain why, and tell us what the organisation is doing to
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Creative Breaks 2017: Grant Application Form
manage this. Also tell us if there have been any recent changes to your financial position which may
not be reflected in your most recent accounts.
Click here to enter text. Maximum 500 words.
6. Previous grants from Short Breaks Fund
List all previous and current grants awarded to your organisation by the Short Breaks Fund.
Year awarded
Type year
Type year
Type year
Type year
Type year
Type year
SBF Programme
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Amount (£)
Enter £
Enter £
Enter £
Enter £
Enter £
Enter £
Reference
Type ref no.
Type ref no.
Type ref no.
Type ref no.
Type ref no.
Type ref no.
SECTION 5: FINAL STEPS BEFORE YOU SEND YOUR APPLICATION
1. Declaration
By submitting this application, you are confirming that:
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You have the authority to submit this application on behalf of your organisation;
The information provided in this application and accompanying documents is true and
accurate;
Your organisation meets the eligibility criteria of the Creative Breaks programme and has the
legal power to set up and deliver the work described in the application;
If your project involves working with children, young people or vulnerable adults you have
the relevant registrations, policies and procedures in place;
Your organisation has appropriate and effective governance and financial management
arrangements in place;
You agree we may use the information you have provided for purposes described under our
Data Protection policy (available to view here).
 Please check you have answered all questions. We can’t start assessing your application until it
is fully complete.
2. Checklist
Please confirm you are attaching the following documents to your email:
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Completed application form
Detailed budget breakdown
Your organisation’s governing document or constitution
A copy of your most recent financial statement or accounts
 Please do not send any other information at this stage.
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