DonMentia

Please answer all questions as failure to complete the form fully and accurately may result in your application being rejected or delayed.

Full Name of the person with the diagnosis of dementia (pwd)

Name (required)

Address (required)

Phone(required)

Email (required)

Name of primary carer
Carer Name (required)

Address if different from pwd
Address (required)

Phone or email

Name of person completing this form
Name (required)

Contact details if different from above
Phone and/or email

Status, if a professional

Relationship to pwd eg spouse, family, friend, carer

Who made the dementia diagnosis eg doctor, psychiatric nurse?

When was the diagnosis completed? Approximate date is sufficient.

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?

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

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.

Have you applied for a grant from DonMentia before? If so, please give brief details.

Please note that, whilst we would love to say 'yes' to every single application, we are having to restrict grants to a maximum of £500 per year per family.

This form will be sent directly to admin@donmentia.org - you should shortly receive a confirmation email.

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