Carefree Short Breaks For Carers Application Form

    Your name

    Your date of birth

    Your email address

    Your phone number

    First line of your address

    Your postcode

    Person/s you care for and their condition

    I consent to my details – name, date of birth, email address – being shared with Carefree. (please tick)
    Yes

    I confirm that I care for 30+ hours a week. (please tick)
    Yes

    I confirm that I understand I will have to pay the £33 fee which covers Carefree’s admin costs. (please tick)
    Yes

    I confirm that I understand that once a referral has been made to Carefree, all future communications regarding booking the break will be between myself (carer) and Carefree. (please tick)
    Yes

    Disclaimer: Carers Bucks are a community partner at Carefree. However, please be advised that we are not responsible for the content of any external websites.