Lennox Children’s Cancer Fund Respite Breaks Application Form – Page 1 of 2
PARENT/GUARDIAN
Parent/Guardian Name
Parent/Guardian Name
Home Address
Postcode
Telephone
Mobile
Employment Situation
CHILD/YOUNG PERSON
Name
Gender
Date of Birth Age
DIAGNOSIS/TREATMENT
Diagnosis
Date of Diagnosis/Relapse
Is the child/young person currently on active treatment Yes No
Date of last active treatment
Hospital
Ward
Consultant Name Telephone
Nurse/Specialist Name Telephone
Nurse/Specialist Based at:
Social Worker Name Telephone
Social Worker Based at:
We ask that you take your child’s up-to-date medical information with you to assist local medical services should their assistance be required during your holiday. Respite Breaks Application Form – Page 2 of 2
HOLIDAY DATES All holidays are for one full week beginning on a Saturday. Please provide three choices of check-in date.
1st Choice Saturday *Please note that school holiday dates are in very high demand. To increase your chance of 2nd Choice Saturday a successful application we highly recommend that at least one of your choices are outside of rd 3 Choice Saturday the school holiday dates.
HOLIDAY LOCATION Please indicate a 1st and 2nd choice of holiday location. If you are only willing to stay at one location, please leave the other box empty. Providing two choices will increase your chances of receiving a holiday. Shorefield Country Park, Shorefield Road, Milford-on-Sea, Hampshire SO41 0LH Lodge (sleeps 8 – 1 double, 1 twin, 1 bunk bed, 1 sofa bed in lounge)
Coopers Beach Holiday Park, Church Lane, East Mersea, Colchester CO5 8TN Caravan (sleeps 6 – 1 double, 1 twin, 1 pull out bed in lounge)
OTHER GUESTS Please give details of everyone expected to be staying in the holiday home during your Respite Break (excluding those already named in this form). Relation to Child/Young Person Full Name Gender Age (i.e. sibling, grandparent, friend)
ADDITIONAL INFORMATION
Car Registration
Please indicate if you require either of the following during your stay. Baby Highchair Travel Cot
SPENDING MONEY A grant of £200 spending money will be provided for each Respite Break. Please provide your bank details below so that we can transfer this directly into your account 1-2 days before your check-in date. Account Name
Account Number Sort Code
Please post your completed form to: Vicky Nash, Lennox Children’s Cancer Fund, Suite D, 7-13 High Street, Romford, Essex RM1 1JU Or email it to: [email protected]