Respite Break Application

This is the application for a respite break in one of our holiday homes at Butlins in Skegness.

This application is subject to the application terms and conditions, which can be downloaded by clicking here, and the resort guest terms and conditions.

Applications for the respite breaks usually take 4-8 weeks to be processed and the final decision on all awards is made by the Charity Trustees.

Respite Breaks

APPLICANT
CHILD
BREAK
CONFIRM

Version 05.22

Section 1 : Applicant Information

Applicant Type

GMC/NMC/HCPC Registration

Title

First Name

Surname

Landline Phone

Mobile Phone

Contact Address

County

Postcode

Section 2 : About The Child

Child's First Name

Child's Surname

Child's Gender

Child's DOB

Child's Address

Child's Parents/Legal Guardian

Is the Child in Hospital/Hospice?

Not In Hospital or Hospice

In Hospital Less Than Week

In Hospital Over a Week

In a Hospice

Does The Child Receive DLA/PIP?

Yes

Application Made

Hospital or Hospice Address

Child's Health Diagnosis

Child's School or Nursery

As part of the application process we need to verify the application with a medical professional, a key worker or social worker. Please supply details of who you would like us to contact to verify your application.

Please note, simply entering 'any doctor' or 'any nurse' etc will mean your application will not be processed. We need a named professional to verify the application.

Verifier Type

Verifier Name

Verifier Phone

Verifier Email

Section 3 : Holiday Breakdown

Please provide further details of the type of break you would like to apply for. Our breaks are to aid the mental health of the child and their immediate family.

Please note: We cannot allow friends or extended family members onto our respite breaks. These breaks are designed for the child, their siblings and parents/carers only.

Holiday Type Preference

We will try to offer you a holiday type that best suits your need, but this is not guaranteed and subject to our availability.

YCT will discuss the availability of our caravans if your application is accepted at the Trustee Meeting.

Please be aware that breaks are provided at the earliest opportunity and may be at short notice.

We have two caravans and we will discuss which one which will best suit your needs after the application is accepted.

Sandhills 246 Accessible Caravan (6 berth)
Sandhills 261 Standard Caravan (8 berth)

We need to provide the details of everyone staying in our caravan to Butlins to provide our breaks, and we will take these details from you if your application is successful, but in the meantime we need to know how many adults and children in your family unit who wish to go on the break.

Accessible Caravan: Our caravan is two bedrooms. The first bedroom has a King size bed. the second bedroom has two full size singles and there is further small double pull-out in the lounge.

Accessible Caravan: Our standard caravan is best suited to families without any additional mobility needs. The first bedroom has a double bed, there are two twin rooms, making three bedrooms in all. There is also a small pull-out in the lounge.

Number of Adults (16+)

Children (2-15)

Babies/Toddlers (under 2)

When was your last holiday?

Within 6 Months

6 Months - 1 Year Ago

Over A Year Ago

Never Had a Holiday

Details of Last Holiday

Section 4 : Confirmation

I confirm the information I have supplied is true and correct and understand it will be processed in line with the application terms and conditions. I understand that providing false or misleading information will result in the application being declined and information may be shared with the police and fraud prevention agencies.

Both the applicant and the parents and/or the legal guardian of the named child consent to the charity using the supplied information in line with GDPR regulations to store and use the data in connection with verifying and processing the application and provide the services of the charity.

Both the applicant and the parents and/or legal guardian of the named child consent to members or agents of the charity contacting Outside Agencies and for them to release sensitive data which will include names, dates of birth, medical conditions and illness details and hospital stays, this is only for the reason of decision making in relation to this support application.

I UNDERSTAND THAT THIS BREAK IS PROVIDED ON AN ACCOMMODATION ONLY BASIS WITH NO FOOD PLAN AND NO ACCESS TO ON-SITE VENUES OR ENTERTAINMENT.

I understand that the break may be subject to change or restrictions due to Covid, Monkeypox or other epidemic or pandemic or local, national or park restrictions.

I understand that if I am accepted for this respite break I will need to pay a £75 Cleaning & Linen Fee as well as a refundable security deposit of £75 that is held against theft, breakages and damages.

Applicant Signature

Please use your mouse or finger to sign your usual signature.

Cookie	Duration	Description
_ga	2 years	This cookie is installed by Google Analytics. The cookie is used to calculate visitor, session, campaign data and keep track of site usage for the site's analytics report. The cookies store information anonymously and assign a randomly generated number to identify unique visitors.
_ga_QYCK085V0S	2 years	This cookie is installed by Google Analytics.

Respite Break Application

Section 1 : Applicant Information

Section 2 : About The Child

Section 3 : Holiday Breakdown

Section 4 : Confirmation

Yorkshire Children’s Trust – a local charity, helping local children

Registered Charity Number 1146884

Horley Green Works • Horley Green Road • Halifax • HX3 6AS