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..

2. Please explain what your holiday/short break will involve e.g. hotel break, respite break, visiting a relative etc..

3. Funding

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.

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