First Name of Carer*

Surname of Carer*

Address line 1*

Address line 2

Town*

Postcode*

Landline Telephone No.

Mobile Telephone No.*

Primary Email Address

Gender*

Date of Birth*

Ethnic Group*

Tell us about your caring role

In this section, it would be really helpful if you could tell us a bit about the following:

• Who you care for
• Their condition(s)
• What your caring role involves
• How this impacts your day-to-day life

This information helps us understand your situation better so we can make a fair decision on your application. It also allows us to offer you the most relevant information, advice, and support tailored to your caring role.*

Cared-For Details

In this section please outline the names and dates of birth of your cared-for(s) and any conditions they may have*

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

Are you new to Carers Gateway?*

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

Have you applied for a Time to Live grant in the last 18 months?*

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

To help us consider your application, please include the following information:

• What would you purchase with your award? (e.g. item/membership/trip etc)
• An approximate idea of the costs involved

Providing these details upfront will help us process your application more smoothly and avoid any delays that might come from us needing to follow up with you.*

How would your purchase make a positive and/or meaningful difference to your caring role?

In this section we would like you to detail the positive impact that accessing the item or trip you are applying for will have on your caring role.

• Highlight the difference it will make
• Describe the impact on your wellbeing, resilience, or ability to continue caring
• Think about emotional, physical or practical benefits.

Give Examples:

• Will it reduce stress, improve your health, give you time to rest, or help you stay socially connected?
• Will it make everyday tasks easier so you can manage caring more effectively?

The more detail you are able to provide us with, the better equipped we will be to make a decision on your application.

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

Who will benefit from this application?

Please let us know who will benefit from this application:

• Just me (an individual application)
• Me and one or more other carers in my household (Joint household application)
• Someone else (please tell us who)
• If more than one carer will benefit, please briefly tell us who they are and their relationship to you.
• Please also detail any cared-fors that may benefit from this application as well

Bank name*

Account Name*

Account Number*

Sort Code*

Is the information provided correct and accurate?*

Date of Application*