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					                                                                                                Holiday date

                                                                                                Deposit paid

                                                                                                Payment Code

                                                                                                Payment received
                                           Application Form 2010
                                                                                                Photos

The price of a Breakaway Caravan Holiday in 2010 is £250.00 plus a returnable deposit of
£50.00. This is for a family of up to 8 persons, (recommended maximum 6) It is not a per
person cost. Families applying must live in the borough of Hammersmith and Fulham.
                                  No Dogs, Pets or bikes/scooters allowed

Name of applicant ?:

Title ......   Name …………………………………………………………………

1. Address? (Please give full address and postcode. You will have to provide proof of residence)
      ………………………………………………………………………………………….

        ………………………………………………………………………………………….


Postcode?


Phone number-
Home:                                                             Mobile:
Email?……………………………………..…. Please tell us of changes especially phone No’s / email addresses.

2. Health needs/Special needs/Disability
Breakaway welcomes people with a disability, health, mental health or special need.

Does anyone in your family have a disability, health or special need?                                    Yes No
Does anyone in your family Use a Wheelchair?                                                             Yes No

Please give as much information below as possible to help us cater for any special
requirement and to give our link workers an understanding of your family’s needs.
……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

………………………………………………………………………if needed please continue on a separate sheet

3. Family Circumstances Breakaway give priority to families who:
    •   have not had a break for more than 3 years
    •   have a member of the family who has a disability or long term medical condition/ has special needs /
        other special circumstances.
    •   are on a low income
    •   are a single parent family

Please tick any boxes, which describe your family’s circumstances.
Family under stress?          (for example family member/child with a disability or special need, chronic
                                              illness, mental health problems or refugee status)
Single Parent family ?
Low-income family?
               Registered Charity No 1114387 Company registered in England & Wales No 5489347
If you have ticked Family under stress, Please give more information to help us help you.
…………………………………………………………………………………………………………

……………………………………………………………                                            if needed continue on a separate sheet


If you ticked Single parent or on a low income, please say why your family needs a holiday.
…………………………………………………………………………………………………………

……………………………………………………………………………………….                                 if needed continue on a separate sheet


4. Date of your last family holiday?………………………

Was this with Breakaway? Yes                   No        Date of last Breakaway Holiday …………………

5. Children and others coming with you?

How many children will accompany you?                              ..........             How many adults? ..........

6. Please list children’s schools? :-

School name 1.                                                                  2.

                 3.                                                                   (if home educated, please state)


7. Help with holiday costs: A Breakaway holiday costs £250.00 + £50.00 deposit
Breakaway has links with charities that may assist with costs. Applicants must be on a low income (e.g. on
income support or the maximum level of child-tax credit) and have had no holiday for 3 years. Financial
support is subject to availability. Evidence of benefit is required.

7 (a) Do you need help with the cost of the holiday from Breakaway?

Yes      (please answer the questions below)                                    No        (please go to question 8)

    (1) Do you receive Income Support?                                                    Yes (go to question 7b) No
    (2) Do you receive Employment and Support Allowance (ESA)                             Yes (go to question 7b) No
        at The Support group rate?                                                        Yes (go to question 7b) No
    (3) Do you receive Child Tax Credit at the maximum rate
    (4) Do you receive ESA at the Work Related Activity rate                              Yes (go to question 7b) No
    (5) Do you receive Jobseekers Allowance (JSA)?
    (6) Do you receive ESA at the Assessment Phase rate                                   Yes (go to question 7b) No

7 (b) Have you attached evidence you currently receive the benefit which you have ticked yes to?

        Yes                                                                          No
                                                                                          (say when you will provide proof?)
If you have difficulty paying the whole cost in one go, it may be possible to pay in instalments from
between the allocation date to 6 Weeks before departure. Please ask if this applies to you.

(If you are not eligible for support through Breakaway and want to discover more about charities who may
help fund your holiday, enquire at your local library or apply to Social Services. Families in receipt of DLA for
a disabled child may also contact the Family Fund, Unit 4, Alpha Court, Monks Cross Drive, Huntington,
York YO32 9WN; as they fund holidays)




                Registered Charity No 1114387 Company registered in England & Wales No 5489347
8 Photographs

    Breakaway would like to use photos of families at Romney Sands for publicity purposes as this
    helps raise money to subsidise the holiday and travel which would otherwise cost over
    £600.00. We can only do this with your permission. Please tick the appropriate box to show
    whether or not you object to your family’s photo appearing in Breakaway publicity.

       I do not object to photos of my family appearing in Breakaway publicity

       I object to photos of my family appearing in Breakaway publicity


9   Declaration

    I declare that all the information I have provided is true and that I understand and agree
    to be bound by the terms and conditions.

        Name                       …………………………………………………………

        Date                       …………………………………………………………


10 Terms and conditions:

I confirm that:-

       I am a resident of the London Borough of Hammersmith & Fulham.
       I enclose photocopy proof of my residence in the Borough of Hammersmith and Fulham.
       I will pay a deposit of £50.00 to secure my holiday, on being offered a holiday date.
       I understand I will have to pay the balance of the holiday payment six weeks before departure.
       I understand only the persons named in question 11 may accompany me without advance written
        permission from Breakaway and that there are no more than eight people in total in my party.
       I understand that if any loss or damage is caused to the caravan or its contents either:
        (a) by myself, those with me, or anyone visiting me, or
        (b) through my negligence in leaving the caravan unattended and unlocked or with windows
        unsecured, I will lose my deposit.
       I will leave the caravan tidy and it and its contents in good condition.
       I promise to respect other participants and staff on the holiday.
       I promise not to bully, argue, fight or use threatening language or behaviour with any
        participants or staff.
       I understand that some of my details will be passed on to Breakaway’s funders, as they may
        require these details. This information is provided as anonymised statistical information and
        used for monitoring purposes only.
       I accept that any decision made by Breakaway management, regarding the holiday is final.
       I understand that my personal belongings are my responsibility at all times and neither
        Breakaway Holiday Project nor Park Resorts can be held responsible for any loss or damage. I
        also understand that insurance cover for cancellation, personal accident and personal belongings
        is my responsibility.
       I understand I cannot bring pets or large play equipment/bikes to Breakaway’s caravans
       I understand that failure to comply with any of these terms and conditions may result in my
        holiday being cancelled, myself and my family being sent home, or my deposit being lost.
       I understand that where financial support is given, accompanying adult/s who are not my partner
        or cohabiting partner will be required to contribute to the cost according to their means.
       I understand that if I cancel the holiday and the place is not reallocated I will lose my deposit.


               Registered Charity No 1114387 Company registered in England & Wales No 5489347
11. Family details
 You must inform the Administrator and gain consent to any changes to this list below well
     before departure. Those not on the link workers list will not be allowed to travel.
1.    Applicant Name?                                                               D.O.B?             AGE?

      Address?:…………………………………………………………………….. Male?                                                      Female?
        &
      Post code…………… phone no? ………………………………………. Special needs: Yes ? No

2     Adult / Child Name?                                                           D.O.B?             AGE?

      Address: (if different from applicant)? ………………………………..                                  Male?    Female?
        &
      Post code…………… phone no? ………………………………………. Special needs: Yes ? No

3     Adult / Child Name?                                                           D.O.B?             AGE?

      Address: (if different from applicant)? ………………………………..                                  Male?    Female?
        &
      Post code…………… phone no? ………………………………………. Special needs: Yes ? No

4     Adult / Child Name?                                                           D.O.B?             AGE?

      Address: (if different from applicant)? ………………………………..                                  Male?    Female?
        &
      Post code…………… phone no? ………………………………………. Special needs: Yes ? No

5     Child Name?                                                                   D.O.B?             AGE?

      Address: (if different from applicant)? ………………………………..                                  Male?    Female?
        &
      Post code/phone………………………………………………………. Special needs:                                            Yes? No?

6     Child Name?                                                                   D.O.B?             AGE?

      Address: (if different from applicant)? ………………………………..                                  Male?    Female?
        &
      Post code…………… phone no? ………………………………………. Special needs: Yes ? No

7     Child Name?                                                                   D.O.B?             AGE?

      Address: (if different from applicant)? ………………………………..                                  Male?    Female?
        &
      Post code…………… phone no? ………………………………………. Special needs: Yes ? No

8     Child Name?                                                                   D.O.B?             AGE?

      Address: (if different from applicant)? ………………………………..                                  Male?    Female?
        &
      Post code…………… phone no? ………………………………………. Special needs: Yes ? No


             Registered Charity No 1114387 Company registered in England & Wales No 5489347

				
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