Shared Care
Building Expectations
Grant application form for the Short Breaks Fund
The Shared Care Short Breaks Fund is a pot of money which ENABLE
Scotland has been asked to administer on behalf of the Scottish Government.
This money is for family carers who look after someone with a learning
disability. The money should be used to help find flexible respite care in a time
and place they choose.
This is money which will be awarded in the form of a grant
therefore will not affect benefits in any way
Help with completing this form
If you need help to complete this form
or have any questions, please contact
ENABLE Direct on 0300 0200 101
or e-mail [email protected]
The information you provide is required
by the Scottish Government to inform
them of who has received the money and
how it was spent. It will not be used for
marketing purposes unless you agree to this.
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(1 ) About You (the primary carer)
Name
Address
Age
Gender
Under 20
20-29
30-39
40-49
50-59
60-69
70-79
80 and over
Male
Female
Are you a member of an ENABLE Scotland Branch?
No
Yes, I am a member of …………………………………………......................Branch.
E-mail
Telephone
Mobile
Number
2
What is your relationship to the person you care for?
Child
Sibling
Niece\Nephew
Other – please explain …………………………………………………………..
Are there any other family carer who also provide support for the person you
care for? If yes please tell us about them.
Name
Age
Gender
Under 20
20-29
30-39
40-49
50-59
60-69
70-79
80 and over
Male
Female
What is their relationship to the person you care for?
Child
Sibling
Niece\Nephew
Other – please explain …………………………………………………………..
If there are more carers please tell us about them in the space at the back of this
form.
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(2) About the person with the learning disability that you care for.
Name
Age
Gender
Under 20
20-29
30-39
40-49
50-59
60-69
70-79
80 and over
Male
Female
Do you or the person you care for currently receive any formal respite services?
Yes
No
If yes, please provide details below. Please state the number of days per year.
(4) About the Grant
Please tell us how much money you wish to apply for (£300 maximum)
£
If you have costs or quotes, please include them with your form.
4
Do you or the person you care for have any health issues?
Yes
No
If yes, please provide details below.
5
About Your (the primary carer’s) Health and Wellbeing
The Warwick-Edinburgh Mental Well-being Scale (WEMWBS)
Below are some statements about feelings and thoughts. Please circle the box
that best describes your experience of each over the last 2 weeks
None of
the
time
Rarely
Some
of the
time
Often
All of
the
time
I’ve been feeling optimistic about
the future
1
2
3
4
5
I’ve been feeling useful
1
2
3
4
5
I’ve been feeling relaxed
1
2
3
4
5
I’ve been feeling interested in other
people
1
2
3
4
5
I’ve had energy to spare
1
2
3
4
5
I’ve been dealing with problems well
1
2
3
4
5
I’ve been thinking clearly
1
2
3
4
5
I’ve been feeling good about myself
1
2
3
4
5
I’ve been feeling close to other
people
1
2
3
4
5
I’ve been feeling confident
1
2
3
4
5
I’ve been able to make up my own
mind about things
1
2
3
4
5
I’ve been feeling loved
1
2
3
4
5
I’ve been interested in new things
1
2
3
4
5
I’ve been feeling cheerful
1
2
3
4
5
Statements
Warwick-Edinburgh Mental Well-Being Scale (WEMWBS)
© NHS Health Scotland, University of Warwick and University of Edinburgh, 2006, all rights reserved.
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(3) About the grant
How much money would you like to apply for? (Maximum £300)
£
Please tell us how the money will be spent.
Amount (£)
Description
Total
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Please use this space for any extra information which may support your application.
Applicants will be assessed on the level of formal respite support currently received
and the potential benefit to the individual and their family.
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(4) Agreement
I confirm that all the details on this form are true and I agree to provide
evidence on how the grant was spent.
Date
Signature
How did you find out about this fund?
Through my ENABLE Scotland Branch
From a flyer
Somewhere else, please explain below.
…………………………………………………………………………………………....
Did you attend an ENABLE Scotland roadshow about this event?
No
Yes, I attended in Arbroath
Yes, I attended in Ayr
Yes, I attended in Hawick
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Please tick the boxes below if you wish to be contacted by ENABLE Scotland in the
future.
Please add me to ENABLE Scotland’s mailing list
I wish to become a member of ENABLE Scotland (This is free).
I would prefer to be contacted by e-mail
I would prefer to be contacted by post
All applications must be submitted in writing, using the specific Short Breaks
application form. Applications should be addressed to:
Business Support
ENABLE Scotland
2nd Floor,
146 Argyle Street
Glasgow,
G2 8BL
Applications are now open and should be received by ENABLE Scotland no later
than the 5th of August 2011.
Any money awarded must be spent by the 30th of September 2011.
ENABLE Scotland National Office Address:
2nd Floor, 146 Argyle Street, Glasgow , G2 8BL
Scottish charity number SC009024
www.enable.org.uk
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