Donmentia Grant for Short Breaks Please answer all questions as failure to complete the form fully and accurately may result in your application being rejected or delayed. 1. Full name of applicant and status of the applicant to person with dementia, e.g husband carer, daughter carer etc.. Applicant's Name (required) Status (required) Name of person with a diagnosis of dementia (required) 2. Please explain what your holiday/short break will involve e.g. hotel break, respite break, visiting a relative etc.. a) Details b) Where is the location of the holiday? c) What date do you intend to go? d) What date will you be returning? 3. Funding a) What is the total cost of the break / holiday? b) How much is being sought from DonMentia to fund this? c) Where, if any, is additional money coming from? e.g self-funded, respite vouchers etc. d) What specifically will the DonMentia grant funds be spent on? e.g hotel costs, travel costs etc. e) Who will benefit from the spending of DonMentia Grant Funds? e.g. yourself, carers and please give a brief description of how you/they will benefit. f) Please use this space for any additional information 4. DonMentia may need to make the relevant checks to ensure that the person has a diagnosis of dementia. We may also request photos and a short testimonial for the DonMentia website. By ticking this box you approve us to do so. Your Email (required) Address Phone number (required) This form will be sent directly to firstname.lastname@example.org - you should shortly receive a confirmation email.