Carers Support Grant 2023/24

All boxes must be completed in full

About You

Full Name of Carer*
Address*
Postcode*
Email* Required for e-vouchers
Contact Number*
Gender*Please select...MaleFemaleNon BinaryTransgenderPrefer not to say
Sexual Orientation*Please select...StraightGayLesbianBi-SexualPrefer not to say
EthnicityPlease select...optgroup-Asian or Asian BritishIndianPakistaniBangladeshiChineseAny other Asian backgroundendoptgroupoptgroup-Black, Black British, Caribbean or AfricanCaribbeanAfricanAny other Black, Black British, or Caribbean backgroundendoptgroupoptgroup-Mixed or multiple ethnic groupsWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or multiple ethnic backgroundendoptgroupoptgroup-WhiteWelshEnglish, Scottish, Northern Irish or BritishIrishGypsy or Irish TravellerRomaAny other White backgroundendoptgroupoptgroup-Other ethnic groupArabAny other ethnic group
Date of Birth*
How many Hours a week do you care?*
How many in Household?*
How many in Household are financially dependant on the carer?*
Do you (the carer) have a chronic illness or disability?*Please select...YesNo
Are you employed?*Please select...Full-TimePart-TimeSelf-EmployedNo
Are you in receiving any welfare benefits?*Please select...YesNo
Please tick ALL benefits you are claimingCarers AllowanceDLA or PIPAttendance AllowanceIncome Support, Working Tax CreditChild Tax CreditHousing BenefitChild SupportCSA
I am applying for this grant because.......you must explain in detail otherwise your application will not be processed*

Information on the person you are caring for

Name of Cared For*
Address of Cared For (if different form Carer)
Relationship to the Carer*
Date of Birth
Gender*Please select...MaleFemaleNon BinaryTransgenderPrefer not to say
Disability/Illness of Cared For*Please select...Autism SpectrumCardiovascularNeurologicalDementia/AlzheimersElderly/InfirmLearning DisabilityMental Health ConditionPhysical IllnessSubstance MisuseOther
If "Other", please specify
Which store voucher do you wish to receive?*Please select...AsdaTescoCurrysArgos
Do you require any other support?*
Do you wish to be referred to our Fuel Poverty team for additional support?*Please select...YesNo
Do you wish to be contacted to have an initial assessment?*Please select...YesNo
I hereby declare that the information given in this application is true and accurate.