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Holiday Lodge Application

We ask you to complete this short application form to make sure we give priority to carers who are most need of a break at the holiday lodges.

  • Name
  • 1. Do you have family or friends who are available to give you time off from caring most of the time when you need it?
  • 2. Are you caring for more than 20 hours a week?
  • 3. Do you live in the same household as the person you are caring for?
  • 4. Is the person you care for in full time education, voluntary or paid employment, and / or do they attend a day centre or engage in a community activity for periods of 6 hours or more in a single day most weeks?
  • 5. Have you been able to have a break from your caring responsibilities for a period of seven days or more in the last year?
  • 6. Have you been looking after you cared for person for more than 8 years?
  • 7. Have your caring responsibilities substantially reduced the amount of time you spend doing social or leisure activities?
  • 8. Would you consider that your physical health is generally good?
  • 9. Would you consider that your mental / emotional health is generally good?
  • 10. Are you currently attending regular appointments with a health care professional? (For example, this could be a G.P., consultant, nurse, Physiotherapist, Occupational Therapist or other health professional)
  • 11. Are you frequently able to switch off from all your caring responsibilities?
  • 12. Are you over 65?
  • 13. Are you in receipt of any means tested benefit and/or in receipt of the highest rate Attendance Allowance, or enhanced rate for daily living of the Personal Independence Payment?
  • 14. Does the person you care for usually have challenging or unpredictable needs or behaviour?
  • Terms and Conditions
    • *I provide unpaid care to another person due to their age, physical or mental illness, learning disability or addiction (you may still receive Carers Allowance).
    • *I agree to answer the questions honestly
    • *I agree to be subject to a check by the Carers Support Service regarding the information I give.
  • Agreement to Terms and Conditions