A service supporting  people who care                       Photo: Timm Sonnenschein    for a relative      or friend  Org...
This leaflet gives details of shortbreaks run by the BirminghamBuddhist Centre in partnershipwith Birmingham City Council,...
Application FormSection 1 - Start here                                   B. Priority need                                 ...
Section 4 - More about you                         Please indicate the kind of room you need                              ...
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Carers relaxation breaks brochure 2012


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Carers relaxation breaks brochure 2012

  1. 1. A service supporting people who care Photo: Timm Sonnenschein for a relative or friend Organised bythe BirminghamBuddhist Centre Photo: Timm Sonnenschein
  2. 2. This leaflet gives details of shortbreaks run by the BirminghamBuddhist Centre in partnershipwith Birmingham City Council,(Adults & Communities Directorate)who provide the funding.The aim is to help carers from Birminghammanage stress and to promote their healthand wellbeing.The breaks offer you a chance to take time outfrom your caring responsibilities in the How to applycompany of other carers. Each break has a Complete the application form opposite,programme of activities which help you detach it and send to the address shown.recharge your batteries and give you ideas andskills you can use at home. We will invite you to the first available weekend when you reach the top of the waiting list.Activities include yoga, meditation, massage,walks but not all of these on every weekend or Six weeks before the break, detailed information about what to bring and how to confirm your placeday. will be sent to you. If you have to turn down theThe weekends and days are provided free of invitation or cancel the place, we will offer you the next available weekend. Our website also has morecharge to carers and include transport from the information: www.livingwellworkingwell.org.ukBuddhist Centre, accommodation, activitiesand all meals. You qualify if you are a relative or For more information about the breaks,friend caring for an adult or child who has a please call Birmingham Carers Centre:disability or long term health problem and wholives in Birmingham. There is no religiouscontent to the weekends. 01 21 2 6 2 3 0 3 6 The weekend breaks start on Friday The venues: Charney Manor afternoons, meeting at the Birmingham A grand and ancient Buddhist Centre in Moseley and travelling by Offa House country house with lovely coach to the venue, returning late afternoon on A handsome house in a gardens, set in an the Sunday. If you need a single room, we can village outside Oxfordshire village. probably help you, otherwise you may to need Leamington Spa. Some Most rooms ensuite. rooms ensuite. About 1 Located about 2 hours to share with one other carer. hour from Birmingham. from Birmingham.“I didnt really know “It comes at a time Photo: Timm Sonnenscheinhow much I really when I most neededneeded this experience a break and I canbut it has helped me so now face the next fewmuch. I am so grateful months feeling positiveto everyone.” and refreshed.”
  3. 3. Application FormSection 1 - Start here B. Priority need Do your caring responsibilities take Yes up a lot of your time and energy? NoHave you been on one of these Relaxation and If the answer is yes, we may be able to offer youStress Management weekend breaks before? another break with several weeks notice. We are No - Please complete sections 2 - 4. aiming to prioritise support for carers who have the greatest need. To help us with those decisions please Yes - Please complete sections 1 - 4. answer the questions below.There are two ways of applying to attend another Are you the only family member / friend Yesbreak if you have already been on one. giving care to the person you look after? NoA. Late availability Do you have health problems which makeWe always have a few spaces for carers who can take it more difficult for you to care, or are Yesa place at very short notice (i.e. a week beforehand) caused by your caring responsibilities? No I have been on one of these breaks before. Does the person you care for have Please put my name on the late availability list. challenging behaviour? (such as may be Yes caused by a learning disability, dementia No or severe mental health problem)Section 2 - About you Section 3 - About the person _________________ that you care forFirst Name:Last Name: _________________ Their name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________Address: __________________ __________________ Relationship to you: _ _ _ _ _ _ _ _ _ _ _ __________________ (e.g. they are YOUR mother, son, friend)Post Code: _ _ _ _ /_ _ _ _ Their address: (only if its different from yours)Telephone No.: _______________ ____________________ ____________________Mobile No.: _________________ ____________________Email: ___________________ _________ Their date of birth:Date of birth: _ _ _ _ _ _ _ _ _ Sex: _ _ _ _ Why they need care:Do you have any special communication needs? (such as BSL, Interpretor, Visually impaired etc) ____________________ ____________________ ______________________ ____________________ ______________________ ______________________ (e.g. mental health problems, learning or physical disability)Ethnic Origin: _______________(This optional question won’t affect your application) A few more questions overleaf >
  4. 4. Section 4 - More about you Please indicate the kind of room you need (eg: because of medical needs)Please give details of someone we can contact inan emergency while you are away with us: Please tick any that apply:Name: __________________ I need a ground floor room __________________ I need a room with an en ensuite bathroomTel. No.: _________________ I need a single room If you want to come with another carer and wouldIs there anything else we need to know to ensure like to share a room with them please give theiryour comfort and safety (eg: mobility problems) name. Note: this carer needs to fill out their own application form. ______________________ ______________________ Name of carer I would like to share a room with: ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Please sign below to confirm that theDo you have any special dietary requirement? information you have given is correct. (eg: vegetarian, vegan, wheat-free, no fish. Signed: Please be specific – eg vegetarian but no eggs so that we can make sure your needs are met.) ______________________ ______________________ ______________________ Date: _________________ Our website has more information: www.livingwellworkingwell.org.ukIf you have any questions about Please send this completed form to:these Carers Breaks, please call Carers Breaksthe Birmingham Carers Centre: Birmingham Buddhist Centre0121 262 3036 11 Park Road Moseley BirminghamData Protection Statement B13 8ABBirmingham Buddhist Centre and BirminghamCity Council follow the Data Protection Act 1998 Printed bywhen using your personal information for booking Central Print,these breaks. For more information, visit Birmingham, onwww.birmingham.gov.uk/privacy 100% recycled paper. Design by Shtig