Respite & recovery application form

Please complete and submit the form below

Surname

Forenames

Address

Contact Number

Email Address

Confirm Email Address

Postcode

D.O.B.

Force (if retired, previous force)

Collar Number

Please tick which of the following criteria apply and provide details on the next page

Experiencing a life changing event e.g. bereavement, relationship break down

Life threatening/changing illness diagnosed within the past 12 months

Acute injury or medical condition

Terminal illness

Diagnosed acute mental illness

In addition to meeting one of the criteria above, to be eligible you must not have accessed a respite break within the past 3 years

I have not accessed a respite break within the past 3 years

Terms

All applications will be assessed by the Clinical Services Manager, applicant will be informed within 7 to 10 working days of the decision.
Member will be informed if further information is required.
One Respite & Recovery break in any 3-year period with our partner holiday company.
Respite & Recovery breaks are limited to two adults and under-18 dependents.
Respite & Recovery breaks must be booked no more than 12 weeks in advance.
Where a booking isn't made within the 12-week time frame, The Ben Fund will follow up once, then the application will be closed.
The Ben Fund will hold a reserve list for any cancellations.

Please provide details to demonstrate you meet the criteria you selected

How can Respite & Recovery assist you?

Please indicate which of the following applies to you:

Currently in work

Recuperative duties

Restricted duties

Sick leave

I can confirm I am a member of The Ben Fund

Personal information which you supply to us may be used in several different ways, for example: To make admission and clinical decisions; for audit and statistical analysis; for fraud prevention.

The Ben Fund is committed to protecting your privacy and security. Whenever you provide personal information, we will treat that information in accordance with UK Data Protection legislation. Further details can be found in our Privacy Policy which can be found on our website at: https://www.thebenfund.co.uk/privacy-policy.

I understand that all personal information on this form will be confidential to the professional and administrative staff of The Ben Fund and no personal information or clinical reports will be shared without my express consent unless required by law.

I agree to The Ben Fund contacting me using the details I have provided.

If successful, I consent to my details being shared with a third-party organisation in relation to the booking of my break.

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