First Name*

Surname*

Address line 1*

Address line 2

Town*

Postcode*

Home phone number

Mobile Telephone No.*

Email address*

Gender*

Date of Birth*

Ethnic Group*

Do you have a disability?*

Do you live with the person you care for?*

Who do you care for?*

Tell us about your caring role*

I currently feel emotionally well*

I have enough time to enjoy activities outside of my caring role*

I feel able to continue in my caring role*

Have you applied for a Time to Live grant in the last 12 months?*

What would you like to use your Time to Live award for?*

How many carers will benefit from this grant?*

How many cared for will benefit from this grant?*

Who will benefit from this application?*

How will this grant give you a meaningful break from your caring role?*

Are you new to Carers Gateway?*

Would you like to register for support in your caring role?*

Would you like someone to contact you about further information / advice / support to help you in your caring role?*

How would you like us to contact you about any aspects of your Time to Live application*

Bank name*

Account Name*

Account Number*

Sort Code*

Is the information provided correct and accurate?*

By applying for Time To Live funding, I agree to completing a Short Break Evaluation. Short break evaluation helps Carers Gateway and Shared Care Scotland evidence that short breaks improve carers’ wellbeing and sustain caring relationships*

Date of Application*