Community Connections Expression of Interest

Please select which service element(s) you are interested in:*

Click the below links to read our terms and conditions before continuing with this form

Community Connections Access to Universal Activities Terms and Conditions
Community Connections Information and Signposting Terms and Conditions
Community Connections Individual Payment Terms and Conditions Easy Read

Consent*

I confirm I have read and understood the terms and conditions for the Community Connections service and agree that the service will meet the needs of my family at this time.

Parent/Carer Full Name*

First Last

Address*

Street Address City County / State / Region Postcode

Telephone/Mobile Number*

Email*

Full Name of Child/Young Person*

First Last

Any other names they may be known as

Age*

In years

Date of Birth*

DD/MM/YYYY

DLA/PIP Rate*

Date awarded until DD/MM/YYYY*

Attach Evidence*

Drop files here or

Accepted file types: pdf, doc, docx, dot, xls, xlsx, jpg, jpeg, png, Max. file size: 15 MB.

Is your child/young person receiving any services from Social Care e.g Direct Payments, respite etc*

Yes
No

Name of Social Worker*

First Last

Please indicate from the list below your child/young person’s primary impairment*

How would you describe your family's ethnic origin*

How did you hear about the service?*

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Please read the attached service requirement below carefully and tick to confirm you agree to the terms and conditions:*

I understand that I need to stay in contact with my advisor by responding to correspondence, and that my account may be closed if contact cannot be made. I understand that I am required to participate in a quarterly review process. This involves completing review forms, providing feedback and case studies – this information forms part of the project monitoring which will be shared with the Cheshire West and Chester council.

I agree to inform my Creative Breaks advisor immediately if there are any changes in circumstances

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I consent to photographs I have provided of my son/daughter enjoying activities funded by the Creative Breaks funding to be used to support and publicise the Short Break Individual Payments service**

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Confirmation

I am happy to receive surveys and information from Disability Positive

Date*

DD/MM/YYYY

Events

No Limits 2025

Activity Groups for Children (Under 18)

Activity Groups for Adults (18+)

Current Vacancies

Volunteer Roles

Disability Confident

Community Connections Expression of Interest

Register your interest

Expression of interest

Click the below links to read our terms and conditions before continuing with this form