Application Form

To help us process your application as quickly as possible, please complete the form as fully as you can.

Important: Please read these notes before completing the form

1. Where applicable to you, please ensure you have the following documents to hand:    

  • Any Disability Living Allowance (DLA)/Personal Independent Payment (PIP) award    
  • Any Education Plan:
           - Additional Support Plan (ASP) or Personal Learning Plan (PLP)
           - Co-ordinated Support Plan (CSP)
           - Individual Education Plan (IEP)    
  • Confirmation of your residential status (Non UK or EU citizens only)


    These documents should be less than 12 months old
    You will be asked to upload copies of these documents at the end of the application form

    2. Please allow yourself around 30 minutes to complete the form.

    3. The closing date for applications is Monday 29th June 2020. Please ensure your application is submitted before 5pm on that day.


  • Your application

    Please enter a valid 7 digit TABS number

    Please select one of the following:


    Please complete
     

    I have been living in Scotland for the past 6 months

     
     

    I am a British citizen

     

    I am an EU citizen

     
     

    If you are not a British or EU citizen, do you have current legal residency in the Scotland and have recourse to Public funds?

    You will be asked to upload your confirmation of residential status at the end of this application form

    I will need an interpreter to talk to Take a Break about my application

     
     

    How did you hear about Take A Break?
    Please select one of the following:
     
     
     
     
     
     
     
     
     
    Please tell us where you heard about Take A Break

    Your details

    This section is about the person who
    a) the child lives with,
    b) has parental responsibility for the child, and
    c) is the child's main carer

    If you are a young person applying on your own behalf, please complete this section with your own details.


    Please enter your title.
    Valid title is required.

    Please complete
    Please complete

    Please complete
    Please enter your date of birth in the format dd/mm/yyyy

    Please complete

    Please complete
    Please enter a valid Post code

    Please enter a valid phone number
    Please include area code if landline number
    Please enter a valid phone number
    Please include area code if landline number

    Please complete

    Your bank account details

    Bank account details are required so that any cash grants can be paid directly into a bank account.

    Please note we are unable to make payments into Post Office accounts. Completing this section does not guarantee a cash grant award.


     

    You have ticked to say that you don’t have a UK bank account in your own name.

    Please continue to complete the rest of your application form, and we will be in touch to tell you how you can opt to have your grant paid into someone else’s account.



     

    You have ticked to say that your only UK bank account is with the Post Office.

    As Take a Break is unable to pay cash grants into Post Office accounts, we will be in touch to tell you how you can opt to have your grant paid into someone else’s account.

    Please continue to complete the rest of your application.


    This should be the same as the name on the Family Fund application
    Please enter your bank account name.
    Must be 6 digits
    Please enter your sort code.
    Please enter your account number.
    Must be between 6 and 8 digits long
    You can find it on your card, statement or passbook

    Child 1 or young person’s details

    Please complete this section for each child you are applying for.
    At the end of this section all the questions can be repeated, allowing you to enter details for more than one disabled child.
    We are unable to process incomplete applications, so please provide as much detail as you can.

    This section MUST be completed.

    Valid first name is required.
    Valid last name is required.

    Please enter a valid date.

    Please select an option


    Please select a valid relationship.
    Please provide other.
    Please enter your relationship.

    Does your child live with you on a full time permanent basis?


    Is your child the subject of a Local Authority care order?


    Is your child in foster care?


    Please tell us your child’s condition or diagnosis

    Please complete
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.


    Please select an option


    Please select an option

    Select the rate of Disability Living Allowance (DLA) or Personal Independence Payment (PIP) your child has been awarded. If you are a young person and you receive DLA/PIP, or if you have told us that your child is in receipt of DLA/PIP, you must send us a copy of the DLA/PIP award with this application.


    Which of the following has your child been awarded:



    Please complete
     


    Please select an option

    Please select an option


    Please select an option

    Please select an option


    Please select an option

    Please tell us the medication needs of your child.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Please select any current treatment or therapy your child is receiving.









    Details required.

    Please select all the equipment used by your child
    Details required.

    Does your child receive respite or short break provision?

    This means formal provision for things like:
  • weekend or evening care
  • activities
  • mentor or buddy schemes to take your child out and about

  • Details required.

    Would your child need support to take part in social and leisure activities?

    Details required.

    Is your child given additional support in Nursery/School or College?

    1:1 support

    Hours per week?

    Details required.

    Small group

    Hours per week?

    Details required.

    Is escorted transport to school provided by the education authority or equivalent?


    Please select any of the following that currently apply.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.

    Please select any of the following that currently apply.

    Details required.

    Who can we speak to?

    We will need the name of your family’s Social Worker, Key Worker/Lead professional, Health Visitor, Teacher or similar who knows your child well (not your GP) and who we can contact for more information.
    Please inform this person that you have given their details to Take a Break as part of making an application.

    This must not be your Doctor
    Please include area code with a landline number


    Child 2 or young person’s details

    Please complete this section for each child you are applying for.
    At the end of this section all the questions can be repeated, allowing you to enter details for more than one disabled child.
    We are unable to process incomplete applications, so please provide as much detail as you can.

    This section MUST be completed.

    Valid first name is required.
    Valid last name is required.

    Please enter a valid date.

    Please select an option


    Please select a valid relationship.
    Please provide other.
    Please enter your relationship.

    Does your child live with you on a full time permanent basis?


    Is your child the subject of a Local Authority care order?


    Is your child in foster care?


    Please tell us your child’s condition or diagnosis

    Please complete
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.


    Please select an option


    Please select an option

    Select the rate of Disability Living Allowance (DLA) or Personal Independence Payment (PIP) your child has been awarded. If you are a young person and you receive DLA/PIP, or if you have told us that your child is in receipt of DLA/PIP, you must send us a copy of the DLA/PIP award with this application.


    Which of the following has your child been awarded:



    Please complete
     


    Please select an option

    Please select an option


    Please select an option

    Please select an option


    Please select an option

    Please tell us the medication needs of your child.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Please select any current treatment or therapy your child is receiving.









    Details required.

    Please select all the equipment used by your child
    Details required.

    Does your child receive respite or short break provision?

    This means formal provision for things like:
  • weekend or evening care
  • activities
  • mentor or buddy schemes to take your child out and about

  • Details required.

    Would your child need support to take part in social and leisure activities?

    Details required.

    Is your child given additional support in Nursery/School or College?

    1:1 support

    Hours per week?

    Details required.

    Small group

    Hours per week?

    Details required.

    Is escorted transport to school provided by the education authority or equivalent?


    Please select any of the following that currently apply.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.

    Please select any of the following that currently apply.

    Details required.

    Who can we speak to?

    We will need the name of your family’s Social Worker, Key Worker/Lead professional, Health Visitor, Teacher or similar who knows your child well (not your GP) and who we can contact for more information.
    Please inform this person that you have given their details to Take a Break as part of making an application.

    This must not be your Doctor
    Please include area code with a landline number


    Child 3 or young person’s details

    Please complete this section for each child you are applying for.
    At the end of this section all the questions can be repeated, allowing you to enter details for more than one disabled child.
    We are unable to process incomplete applications, so please provide as much detail as you can.

    This section MUST be completed.

    Valid first name is required.
    Valid last name is required.

    Please enter a valid date.

    Please select an option


    Please select a valid relationship.
    Please provide other.
    Please enter your relationship.

    Does your child live with you on a full time permanent basis?


    Is your child the subject of a Local Authority care order?


    Is your child in foster care?


    Please tell us your child’s condition or diagnosis

    Please complete
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.


    Please select an option


    Please select an option

    Select the rate of Disability Living Allowance (DLA) or Personal Independence Payment (PIP) your child has been awarded. If you are a young person and you receive DLA/PIP, or if you have told us that your child is in receipt of DLA/PIP, you must send us a copy of the DLA/PIP award with this application.


    Which of the following has your child been awarded:



    Please complete
     


    Please select an option

    Please select an option


    Please select an option

    Please select an option


    Please select an option

    Please tell us the medication needs of your child.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Please select any current treatment or therapy your child is receiving.









    Details required.

    Please select all the equipment used by your child
    Details required.

    Does your child receive respite or short break provision?

    This means formal provision for things like:
  • weekend or evening care
  • activities
  • mentor or buddy schemes to take your child out and about

  • Details required.

    Would your child need support to take part in social and leisure activities?

    Details required.

    Is your child given additional support in Nursery/School or College?

    1:1 support

    Hours per week?

    Details required.

    Small group

    Hours per week?

    Details required.

    Is escorted transport to school provided by the education authority or equivalent?


    Please select any of the following that currently apply.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.

    Please select any of the following that currently apply.

    Details required.

    Who can we speak to?

    We will need the name of your family’s Social Worker, Key Worker/Lead professional, Health Visitor, Teacher or similar who knows your child well (not your GP) and who we can contact for more information.
    Please inform this person that you have given their details to Take a Break as part of making an application.

    This must not be your Doctor
    Please include area code with a landline number


    Child 4 or young person’s details

    Please complete this section for each child you are applying for.
    At the end of this section all the questions can be repeated, allowing you to enter details for more than one disabled child.
    We are unable to process incomplete applications, so please provide as much detail as you can.

    This section MUST be completed.

    Valid first name is required.
    Valid last name is required.

    Please enter a valid date.

    Please select an option


    Please select a valid relationship.
    Please provide other.
    Please enter your relationship.

    Does your child live with you on a full time permanent basis?


    Is your child the subject of a Local Authority care order?


    Is your child in foster care?


    Please tell us your child’s condition or diagnosis

    Please complete
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.


    Please select an option


    Please select an option

    Select the rate of Disability Living Allowance (DLA) or Personal Independence Payment (PIP) your child has been awarded. If you are a young person and you receive DLA/PIP, or if you have told us that your child is in receipt of DLA/PIP, you must send us a copy of the DLA/PIP award with this application.


    Which of the following has your child been awarded:



    Please complete
     


    Please select an option

    Please select an option


    Please select an option

    Please select an option


    Please select an option

    Please tell us the medication needs of your child.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Please select any current treatment or therapy your child is receiving.









    Details required.

    Please select all the equipment used by your child
    Details required.

    Does your child receive respite or short break provision?

    This means formal provision for things like:
  • weekend or evening care
  • activities
  • mentor or buddy schemes to take your child out and about

  • Details required.

    Would your child need support to take part in social and leisure activities?

    Details required.

    Is your child given additional support in Nursery/School or College?

    1:1 support

    Hours per week?

    Details required.

    Small group

    Hours per week?

    Details required.

    Is escorted transport to school provided by the education authority or equivalent?


    Please select any of the following that currently apply.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.

    Please select any of the following that currently apply.

    Details required.

    Who can we speak to?

    We will need the name of your family’s Social Worker, Key Worker/Lead professional, Health Visitor, Teacher or similar who knows your child well (not your GP) and who we can contact for more information.
    Please inform this person that you have given their details to Take a Break as part of making an application.

    This must not be your Doctor
    Please include area code with a landline number


    Child 5 or young person’s details

    Please complete this section for each child you are applying for.
    At the end of this section all the questions can be repeated, allowing you to enter details for more than one disabled child.
    We are unable to process incomplete applications, so please provide as much detail as you can.

    This section MUST be completed.

    Valid first name is required.
    Valid last name is required.

    Please enter a valid date.

    Please select an option


    Please select a valid relationship.
    Please provide other.
    Please enter your relationship.

    Does your child live with you on a full time permanent basis?


    Is your child the subject of a Local Authority care order?


    Is your child in foster care?


    Please tell us your child’s condition or diagnosis

    Please complete
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.


    Please select an option


    Please select an option

    Select the rate of Disability Living Allowance (DLA) or Personal Independence Payment (PIP) your child has been awarded. If you are a young person and you receive DLA/PIP, or if you have told us that your child is in receipt of DLA/PIP, you must send us a copy of the DLA/PIP award with this application.


    Which of the following has your child been awarded:



    Please complete
     


    Please select an option

    Please select an option


    Please select an option

    Please select an option


    Please select an option

    Please tell us the medication needs of your child.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Please select any current treatment or therapy your child is receiving.









    Details required.

    Please select all the equipment used by your child
    Details required.

    Does your child receive respite or short break provision?

    This means formal provision for things like:
  • weekend or evening care
  • activities
  • mentor or buddy schemes to take your child out and about

  • Details required.

    Would your child need support to take part in social and leisure activities?

    Details required.

    Is your child given additional support in Nursery/School or College?

    1:1 support

    Hours per week?

    Details required.

    Small group

    Hours per week?

    Details required.

    Is escorted transport to school provided by the education authority or equivalent?


    Please select any of the following that currently apply.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.

    Please select any of the following that currently apply.

    Details required.

    Who can we speak to?

    We will need the name of your family’s Social Worker, Key Worker/Lead professional, Health Visitor, Teacher or similar who knows your child well (not your GP) and who we can contact for more information.
    Please inform this person that you have given their details to Take a Break as part of making an application.

    This must not be your Doctor
    Please include area code with a landline number


    Child 6 or young person’s details

    Please complete this section for each child you are applying for.
    At the end of this section all the questions can be repeated, allowing you to enter details for more than one disabled child.
    We are unable to process incomplete applications, so please provide as much detail as you can.

    This section MUST be completed.

    Valid first name is required.
    Valid last name is required.

    Please enter a valid date.

    Please select an option


    Please select a valid relationship.
    Please provide other.
    Please enter your relationship.

    Does your child live with you on a full time permanent basis?


    Is your child the subject of a Local Authority care order?


    Is your child in foster care?


    Please tell us your child’s condition or diagnosis

    Please complete
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.


    Please select an option


    Please select an option

    Select the rate of Disability Living Allowance (DLA) or Personal Independence Payment (PIP) your child has been awarded. If you are a young person and you receive DLA/PIP, or if you have told us that your child is in receipt of DLA/PIP, you must send us a copy of the DLA/PIP award with this application.


    Which of the following has your child been awarded:



    Please complete
     


    Please select an option

    Please select an option


    Please select an option

    Please select an option


    Please select an option

    Please tell us the medication needs of your child.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Please select any current treatment or therapy your child is receiving.









    Details required.

    Please select all the equipment used by your child
    Details required.

    Does your child receive respite or short break provision?

    This means formal provision for things like:
  • weekend or evening care
  • activities
  • mentor or buddy schemes to take your child out and about

  • Details required.

    Would your child need support to take part in social and leisure activities?

    Details required.

    Is your child given additional support in Nursery/School or College?

    1:1 support

    Hours per week?

    Details required.

    Small group

    Hours per week?

    Details required.

    Is escorted transport to school provided by the education authority or equivalent?


    Please select any of the following that currently apply.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.

    Please select any of the following that currently apply.

    Details required.

    Who can we speak to?

    We will need the name of your family’s Social Worker, Key Worker/Lead professional, Health Visitor, Teacher or similar who knows your child well (not your GP) and who we can contact for more information.
    Please inform this person that you have given their details to Take a Break as part of making an application.

    This must not be your Doctor
    Please include area code with a landline number


    Child 7 or young person’s details

    Please complete this section for each child you are applying for.
    At the end of this section all the questions can be repeated, allowing you to enter details for more than one disabled child.
    We are unable to process incomplete applications, so please provide as much detail as you can.

    This section MUST be completed.

    Valid first name is required.
    Valid last name is required.

    Please enter a valid date.

    Please select an option


    Please select a valid relationship.
    Please provide other.
    Please enter your relationship.

    Does your child live with you on a full time permanent basis?


    Is your child the subject of a Local Authority care order?


    Is your child in foster care?


    Please tell us your child’s condition or diagnosis

    Please complete
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.


    Please select an option


    Please select an option

    Select the rate of Disability Living Allowance (DLA) or Personal Independence Payment (PIP) your child has been awarded. If you are a young person and you receive DLA/PIP, or if you have told us that your child is in receipt of DLA/PIP, you must send us a copy of the DLA/PIP award with this application.


    Which of the following has your child been awarded:



    Please complete
     


    Please select an option

    Please select an option


    Please select an option

    Please select an option


    Please select an option

    Please tell us the medication needs of your child.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Please select any current treatment or therapy your child is receiving.









    Details required.

    Please select all the equipment used by your child
    Details required.

    Does your child receive respite or short break provision?

    This means formal provision for things like:
  • weekend or evening care
  • activities
  • mentor or buddy schemes to take your child out and about

  • Details required.

    Would your child need support to take part in social and leisure activities?

    Details required.

    Is your child given additional support in Nursery/School or College?

    1:1 support

    Hours per week?

    Details required.

    Small group

    Hours per week?

    Details required.

    Is escorted transport to school provided by the education authority or equivalent?


    Please select any of the following that currently apply.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.

    Please select any of the following that currently apply.

    Details required.

    Who can we speak to?

    We will need the name of your family’s Social Worker, Key Worker/Lead professional, Health Visitor, Teacher or similar who knows your child well (not your GP) and who we can contact for more information.
    Please inform this person that you have given their details to Take a Break as part of making an application.

    This must not be your Doctor
    Please include area code with a landline number


    Child 8 or young person’s details

    Please complete this section for each child you are applying for.
    At the end of this section all the questions can be repeated, allowing you to enter details for more than one disabled child.
    We are unable to process incomplete applications, so please provide as much detail as you can.

    This section MUST be completed.

    Valid first name is required.
    Valid last name is required.

    Please enter a valid date.

    Please select an option


    Please select a valid relationship.
    Please provide other.
    Please enter your relationship.

    Does your child live with you on a full time permanent basis?


    Is your child the subject of a Local Authority care order?


    Is your child in foster care?


    Please tell us your child’s condition or diagnosis

    Please complete
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.


    Please select an option


    Please select an option

    Select the rate of Disability Living Allowance (DLA) or Personal Independence Payment (PIP) your child has been awarded. If you are a young person and you receive DLA/PIP, or if you have told us that your child is in receipt of DLA/PIP, you must send us a copy of the DLA/PIP award with this application.


    Which of the following has your child been awarded:



    Please complete
     


    Please select an option

    Please select an option


    Please select an option

    Please select an option


    Please select an option

    Please tell us the medication needs of your child.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Please select any current treatment or therapy your child is receiving.









    Details required.

    Please select all the equipment used by your child
    Details required.

    Does your child receive respite or short break provision?

    This means formal provision for things like:
  • weekend or evening care
  • activities
  • mentor or buddy schemes to take your child out and about

  • Details required.

    Would your child need support to take part in social and leisure activities?

    Details required.

    Is your child given additional support in Nursery/School or College?

    1:1 support

    Hours per week?

    Details required.

    Small group

    Hours per week?

    Details required.

    Is escorted transport to school provided by the education authority or equivalent?


    Please select any of the following that currently apply.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.

    Please select any of the following that currently apply.

    Details required.

    Who can we speak to?

    We will need the name of your family’s Social Worker, Key Worker/Lead professional, Health Visitor, Teacher or similar who knows your child well (not your GP) and who we can contact for more information.
    Please inform this person that you have given their details to Take a Break as part of making an application.

    This must not be your Doctor
    Please include area code with a landline number


    Child 9 or young person’s details

    Please complete this section for each child you are applying for.
    At the end of this section all the questions can be repeated, allowing you to enter details for more than one disabled child.
    We are unable to process incomplete applications, so please provide as much detail as you can.

    This section MUST be completed.

    Valid first name is required.
    Valid last name is required.

    Please enter a valid date.

    Please select an option


    Please select a valid relationship.
    Please provide other.
    Please enter your relationship.

    Does your child live with you on a full time permanent basis?


    Is your child the subject of a Local Authority care order?


    Is your child in foster care?


    Please tell us your child’s condition or diagnosis

    Please complete
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.


    Please select an option


    Please select an option

    Select the rate of Disability Living Allowance (DLA) or Personal Independence Payment (PIP) your child has been awarded. If you are a young person and you receive DLA/PIP, or if you have told us that your child is in receipt of DLA/PIP, you must send us a copy of the DLA/PIP award with this application.


    Which of the following has your child been awarded:



    Please complete
     


    Please select an option

    Please select an option


    Please select an option

    Please select an option


    Please select an option

    Please tell us the medication needs of your child.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Please select any current treatment or therapy your child is receiving.









    Details required.

    Please select all the equipment used by your child
    Details required.

    Does your child receive respite or short break provision?

    This means formal provision for things like:
  • weekend or evening care
  • activities
  • mentor or buddy schemes to take your child out and about

  • Details required.

    Would your child need support to take part in social and leisure activities?

    Details required.

    Is your child given additional support in Nursery/School or College?

    1:1 support

    Hours per week?

    Details required.

    Small group

    Hours per week?

    Details required.

    Is escorted transport to school provided by the education authority or equivalent?


    Please select any of the following that currently apply.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.

    Please select any of the following that currently apply.

    Details required.

    Who can we speak to?

    We will need the name of your family’s Social Worker, Key Worker/Lead professional, Health Visitor, Teacher or similar who knows your child well (not your GP) and who we can contact for more information.
    Please inform this person that you have given their details to Take a Break as part of making an application.

    This must not be your Doctor
    Please include area code with a landline number


    Child 10 or young person’s details

    Please complete this section for each child you are applying for.
    At the end of this section all the questions can be repeated, allowing you to enter details for more than one disabled child.
    We are unable to process incomplete applications, so please provide as much detail as you can.

    This section MUST be completed.

    Valid first name is required.
    Valid last name is required.

    Please enter a valid date.

    Please select an option


    Please select a valid relationship.
    Please provide other.
    Please enter your relationship.

    Does your child live with you on a full time permanent basis?


    Is your child the subject of a Local Authority care order?


    Is your child in foster care?


    Please tell us your child’s condition or diagnosis

    Please complete
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid last name is required.


    Please select an option


    Please select an option

    Select the rate of Disability Living Allowance (DLA) or Personal Independence Payment (PIP) your child has been awarded. If you are a young person and you receive DLA/PIP, or if you have told us that your child is in receipt of DLA/PIP, you must send us a copy of the DLA/PIP award with this application.


    Which of the following has your child been awarded:



    Please complete
     


    Please select an option

    Please select an option


    Please select an option

    Please select an option


    Please select an option

    Please tell us the medication needs of your child.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.
    Valid first name is required.
    Valid first name is required.
    Valid last name is required.

    Please select any current treatment or therapy your child is receiving.









    Details required.

    Please select all the equipment used by your child
    Details required.

    Does your child receive respite or short break provision?

    This means formal provision for things like:
  • weekend or evening care
  • activities
  • mentor or buddy schemes to take your child out and about

  • Details required.

    Would your child need support to take part in social and leisure activities?

    Details required.

    Is your child given additional support in Nursery/School or College?

    1:1 support

    Hours per week?

    Details required.

    Small group

    Hours per week?

    Details required.

    Is escorted transport to school provided by the education authority or equivalent?


    Please select any of the following that currently apply.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.
    Please enter a valid date.

    Please select any of the following that currently apply.

    Details required.

    Who can we speak to?

    We will need the name of your family’s Social Worker, Key Worker/Lead professional, Health Visitor, Teacher or similar who knows your child well (not your GP) and who we can contact for more information.
    Please inform this person that you have given their details to Take a Break as part of making an application.

    This must not be your Doctor
    Please include area code with a landline number

    Your Take a Break grant

    Under the current government guidelines, due to coronavirus, many restrictions have been placed on travel including short breaks and day trips.

    You do have 12 months to use your grant, but if you’d prefer not to use this year’s grant for a short break, you can request a grant for a range of other items that would help support a break at home. This could be for bikes, sports equipment, outdoor play or home entertainment, please just tell us what you would use your grant for, in the sections below.

    We expect our average grant to be between £250 and £300; please include an approximate cost against each section.

    Details required.

    Details required.
    £
    Details required

    Will you need an extra carer to help you?

    £
    Please complete
    Details required

    Would you need any equipment / sports equipment or similar to take part in your activity?

    £
    Details required

    Details required.
    £
    Details required

    £
    Please complete
    Details required

    Details required.

    Your documents

    Please upload a copy of any current DLA/PIP award documents, applicable to you/your child(ren). These must be no more than 12 months old.

    This file is too large and will not be uploaded. Please choose a file under 2MB




    You may upload a maximum of 3 files in .jpeg, .gif, .png or .pdf format. Files must be less than 2MB in size.



    Please upload a copy of any recent Education Plan applicable to you/your child(ren). These could be; Additional Support Plan (ASP), Co-ordinated Support Plan (CSP) or Individual Education Plan (IEP). These must be no more than 12 months old.





    You may upload a maximum of 3 files in .jpeg, .gif, .png or .pdf format. Files must be less than 2MB in size.



    As you have ticked to say you are not a UK or EU citizen, please upload a copy of your confirmation of residential status.

    You may upload a file in .jpeg, .gif, .png or .pdf format. Files must be less than 2MB in size.



    If you are unable to upload documents using your device, or you have more documents than can be uploaded here, then please email them to info@takeabreakscotland.org.uk To avoid delays in processing your application, please ensure that you quote the reference number that will be provided to you in the confirmation screen and email (after you have clicked submit application)


    Your agreement

    Our Terms & Conditions and Data Protection Statement can be found on the ‘How to Apply’ section of our website www.familyfund.org.uk. We intend to rely on the terms contained within those documents so for your own benefit and protection, please read them carefully before signing and submitting the application. If you do not understand any points please ask us for further information.

    By submitting your application to us you will be providing us with your explicit consent to us using the information contained within the application and any subsequent related correspondence with you for the purposes of:

    1. processing and considering your application (including to understand whether your child meets our Child and Young Persons Eligibility Criteria, whether you and your family circumstances meet our relevant criteria and, if so, how we can help you and best provide support to you), and discussing your application with you where necessary; and


    2. if your application is successful, informing you of any subsequent grants, advice or other support services that we are able to provide within 12 months of your award date


    If using a mobile device to view these links, you will need to navigate back to this page to continue to submit your application.