Apply for funding

Use this form whether you are applying on behalf of yourself or someone else.

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Comments

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Grant Terms and Conditions*

By submitting this application, you agree to Revitalise’s grant terms and conditions, which include:

Using the grant only for the purpose stated in your application
Completing a short impact report form after your break/activity
Returning a signed acceptance form if your application is successful
Providing accurate information (false information may result in grant being reclaimed)

Please note:
Revitalise provides grant funding only. We are not party to your booking contract with the provider.

You are responsible for booking directly with your chosen provider. Before confirming, please make sure they can meet your specific needs, including any care or accessibility requirements.

You are responsible for arranging appropriate travel insurance for your trip.

We will collect personal data as part of this application. Please read our Privacy Notice to understand how we use your information.

I agree to Revitalise’s grant terms and conditions.

Personal Details

Name*

Title First Last

Address*

Street Address Address Line 2 Town / City Postcode

Contact Details

Please provide at least one way for us to contact you.

Preferred contact method*

If you prefer post, we’ll send letters to your previously provided address.

Phone

Post

Email*

Enter Email Confirm Email

Phone*

Age Confirmation

Age Confirmation*

Our grants are for people aged 18 years of age or over.

I confirm I am 18 years of age or over

Age Range

To help us understand who we are supporting, would you be willing to share your age range?This is completely optional and will not affect your application decision.

18-24

25-34

35-44

45-54

55-64

65-74

75 or over

Prefer not to say

Who You Are

Are you*

A disabled person

A carer applying on behalf of a disabled person

A carer applying for yourself

Is someone helping you complete this application?*

Yes

Helper's Details

Helper's Name*

Prefix First Last

Helper's Email*

Enter Email Confirm Email

Helper's Phone*

Helper's Organisation

If applicable.

Relationship to you*

e.g., family member, support worker, friend, carer.

Applicant Consent*

I confirm that:

I have asked my helper to help me complete this application
I understand what information is being provided
I consent to this information being submitted on my behalf
I give permission for Revitalise to contact my helper about my application if needed

Explanation

If you are unable to provide consent yourself, please have your helpers explain your circumstances below and provide their contact details. We may need to conduct additional verification.

Helper Declaration*

I confirm that:

I have the applicant’s permission to complete this form
I have explained what information I am providing
The information I have provided is accurate to the best of my knowledge
I understand Revitalise may contact me to verify this application

Disability Information

Do you have a disability as defined by the Equality Act 2010?*

A physical or mental impairment with substantial, long-term effect on daily activities.

Yes

Do any conditions or illnesses affect you in any of the following areas?*

Please tick all that apply.

Vision (for example blindness or partial sight)

Hearing (for example deafness or partial hearing)

Mobility (for example walking short distances or climbing stairs)

Dexterity (for example lifting and carrying objects, using a keyboard)

Learning or understanding or concentrating

Memory

Mental health

Stamina or breathing or fatigue

Socially or behaviourally (for example associated with autism spectrum disorder (ASD) which includes Asperger’s, or attention deficit hyperactivity disorder (ADHD))

Other (please specify)

Other conditions or illnesses affect you*

Brief confirmation

Optional but helpful.
Please briefly describe how your disability affects you. You do not need to provide medical diagnoses or detailed symptoms.

Care Support

Do you require care support in your daily life?*

Yes

Brief description*

If yes, please briefly describe the type of support you need. You don’t need to provide intimate personal care details.

Note: It’s your responsibility to ensure your chosen holiday provider can meet your specific care needs. We recommend discussing your requirements with them directly before booking.

Disability Information

Does the person you support have a disability as defined by the Equality Act 2010?*

A physical or mental impairment with substantial, long-term effect on daily activities.

Yes

Do any conditions or illnesses affect the person you support in any of the following areas?*

Please tick all that apply.

Vision (for example blindness or partial sight)

Hearing (for example deafness or partial hearing)

Mobility (for example walking short distances or climbing stairs)

Dexterity (for example lifting and carrying objects, using a keyboard)

Learning or understanding or concentrating

Memory

Mental health

Stamina or breathing or fatigue

Socially or behaviourally (for example associated with autism spectrum disorder (ASD) which includes Asperger’s, or attention deficit hyperactivity disorder (ADHD))

Other (please specify)

Other conditions or illnesses*

Brief confirmation

Optional but helpful.
Please briefly describe how their disability affects them. You do not need to provide medical diagnoses or detailed symptoms.

Types And Levels Of Care

What type of care and support do you personally provide?*

Personal care (washing, dressing, toileting, feeding)

Mobility assistance (helping them move around, transfers, getting in/out of bed)

Medication management (administering, reminding, organizing)

Household tasks (cooking, cleaning, shopping, laundry)

Managing appointments and healthcare coordination

Financial and administrative support

Emotional support and companionship

Supervision for safety (ensuring they don’t come to harm)

Communication support (speaking for them, interpreting their needs)

Night-time care (waking during the night to provide care)

Other (please specify)

Other types of care and support personally provided*

Please provide one brief example of the level of care required*

Example: “I provide personal care 3 times daily, manage all medications, and supervise constantly as they cannot be left alone safely.”.

On average, how many hours of care support do you provide a week*

9 hours or less

10 – 19 hours

20 – 34 hours

35 – 59 hours

50+

Current Circumstances

Please tell us about how you are feeling now. If you receive a grant, we’ll ask you the same questions after you’ve used it. This will help us know what difference we are making.

Overall, how satisfied are you with your life nowadays?*

On a scale of 0 to 10, where 0 is “not at all” and 10 is “completely”.

Please enter a number from 0 to 10.

Please say what best describes your experience of each over the last 2 weeks.*

Below are some statements about feelings and thoughts.

	None of the time	Rarely	Some of the time	Often	All of the time
I’ve been feeling optimistic about the future
I’ve been feeling useful
I’ve been feeling relaxed
I’ve been dealing with problems well
I’ve been thinking clearly
I’ve been feeling close to other people
I’ve been able to make up my own mind about things

Thinking about the last year, have you been able to*

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Not sure
Go out and do something you enjoy?
Enjoy other people’s company?
Have a break when you’ve needed one?

Financial Eligibility

To assess your application fairly, we need to understand your financial situation. Our grants are for people who couldn’t otherwise afford a respite break.

Please help us by providing information about your circumstances:

Do you currently receive any means-tested benefits?*

Yes

Benefit provider*

You don’t need to provide amounts or proof at this stage.
Examples: Universal Credit, Pension Credit, Housing Benefit, ESA, Income Support, etc.

Are you currently working?*

Yes, full-time

Yes, part-time

No, unable to work due to disability/health/caring responsibilities

No, retired

No, other reason

Approximate household income (before tax)*

Under £15,000 per year

£15,000 – £25,000

£25,000 – £35,000

Over £35,000

Do you have significant care costs or medical expenses?*

Yes

Please briefly explain the significant care costs or medical expenses*

Do you have savings over £6,000?*

Yes

Please briefly explain why you're unable to fund this break yourself*

Application Details

Please tell us about the break or respite activity you would like to take. To be issued a grant for a respite holiday, you will need a provisional booking in place. For day activities, you do not need a provisional booking.

Type of Break*

Holiday accommodation (hotel, cottage, caravan, holiday park)

Day trips or outings

Activity or experience (e.g., theatre, concert, attraction)

Respite care facility stay

Other (please specify)

Other type of break*

Location or Activity Name*

Name of accommodation, location, or activity.

Provisional date*

e.g., “July 2025” or “Summer 2025”.

Estimated Cost Breakdown

Accommodation or Activity Cost*

Travel costs*

Other costs*

Total estimated cost*

Amount Requesting from Revitalise*

Are you receiving funding from any other sources for this break?

Yes

Applied and awaiting decision from

Please specify source of additional funding*

Please specify amount of additional funding*

Awaiting decision from*

I'd like to make an exceptional funding request*

As a reminder, our usual funding amounts are £500 towards the cost of a respite break or holiday and up to £100 towards a day trip or activity, or other opportunity for social connection. If you would like to apply for more than this, or you feel your application is particularly urgent, please let us know below.

Exceptional circumstances are usually, but not limited to, the following:

Carer breakdown
Extreme hardship
People in palliative care whose last chance it is to take a break

Yes

Exceptional Funding Request

Our standing grant size is £500 (respite break) or £100 (day trip/activity).

If you need more than this due to exceptional circumstances, please answer the following questions.

Exceptional circumstance*

Palliative care

Carer breakdown/urgent need

Severe financial hardship

Other (please specify)

Other exceptional circumstance*

Briefly explain exceptional circumstance*

Additional amount requested*

As a reminder, our usual funding amounts are £500 towards the cost of a respite break or holiday and up to £100 towards a day trip or activity, or other opportunity for social connection.

How Would This Break Help You?

Please briefly explain how this break would benefit you*

Note: Please focus on how the break would help you generally. You do not need to include detailed medical information or describe your condition in depth.

Group Application

Is this part of a group trip?*

Yes

Names of other group members*

By providing these names, you confirm these people are aware you’ve included them in your application, and they consent to us holding their names for coordination purposes. The other members will need to send us their applications separately.

Previous Funding

We give priority to people who have not had funding from us in the last 12 months.

Have you received funding from us before?*

Yes

Was this more than 12 months ago?*

Yes

How Did You Hear About Us?

This helps us understand where to focus our outreach efforts. It’s completely optional and won’t affect your application.

How did you hear about us?

Google search

Social media (Facebook, Twitter, etc.)

Referral from another charity

Healthcare professional (GP, nurse, social worker)

Friend or family member

Local authority/council

Previous guest of Revitalise

Other (please specify)

Prefer not to say

Which other location did you hear about us from?*

Revitalise Funding

If Revitalise is able to help, you will receive a formal offer letter via post or email which you will need to accept.

You will need to sign this offer letter and you will also need to get it signed by someone who can confirm that what you have stated in your application about your disability or illness and your eligibility for funding is true.

This can be a doctor, district nurse, social worker, charity worker or faith leader.

If you have been referred to us via another Registered Charity, one of their officers can sign the form for you.

A relative or friend cannot sign the form for you.

Would you like the form posted to you?

If you will not be able to print this form yourself, please select ‘yes’.

Yes

Equality Monitoring

We are committed to ensuring our grants reach diverse communities. This section is completely optional and will not affect your application in any way.

You do not have to answer these questions. Your application will be assessed only on the information above.

Gender

Female

Male

Non-binary

Prefer to self-describe

Prefer not to say

Ethnic group

Asian or Asian British

Black, African, Caribbean or Black British

Mixed or Multiple ethnic groups

White

Other ethnic group

Prefer not to say