Short breaks & support for families with cancer

Full name*

Phone number*

Email address*

Enquiry type*

How can we help?

Family Surname*

Address (please give FULL home address including postcode)*

Post Code*

Preferred date for stay Please give 3 choices of dates (with your preferred date first)

From*

To*

From

To

From

To

Please note our bookings run from a Saturday to the following Friday. Saturday - Arrival – 1pm or 2pm (time arranged by telephone prior to arriving). Friday – Departure by 10.30am

Number of guests*

Please enter a value between 1 and 6.

Each cottage sleeps a maximum of 6 individuals. Travel cots available on request.

Child Booking Information

Child/Young Person with diagnosis*

Date of Birth*

Male/female*

School (if attending)*

Diagnosis (include date)*

Current Treatment*

Treatment Centre*

Consultant/Social Work/Support Team*

Your Family
We need to know about your family to help make sure that your stay is as comfortable as possible.
IMPORTANT - Only those listed on this Booking Form are authorised to stay at the retreat.

*

Name	Age	Relationship to child/young person

Additional Items

Select All
Wheelchair access
Portable Hoist (Molift Smart 150)
Shower Cradle (Washington Shower Cradle Medium)
Splashy - Portable seat for bathing (age 1-8 or 30kg max)
Profile Bed* *Please note that the Profile Bed single and is located in one of our twin rooms.
Travel Cot / Baby Bath (Please note that bedding not provided for the travel cot)
Highchair
Oxygen - if your child/young person will be using this during their respite then please indicate. You must arrange for delivery/uplift yourself, we do not supply etc

Please indicate if you require access or use of any items above; please note that we have shower facilities only (no bath in either cottage)

Clinical Care
Unless you have been referred by a health/social care or educational organisation then we require a copy of a clinical letter issued by a consultant/treatment centre/social worker etc.

*

I am happy to provide a clinical letter
I would like Whiteleys Retreat to securely share this information with Crosshouse Hospital Paediatrics Dept. who can offer clinical support or advice should it be required.

Reasons for Respite/How does your child/young person's illness or condition affect them and your family on a day-to-day basis?*

*

Important Information

Please see below and sign that you have read and understood the following information -

Onsite

Whiteleys Retreat operates a NO SMOKING policy within our properties.
No pets are allowed to stay at the retreat.
Whiteleys Retreat holds no responsibility for food allergies and any risks should be assessed by families.

Booking/Evaluation

Please note that only ONE booking can be made at any time; a family can book once in a 12-month period unless there are exceptional circumstances.
By completing this form, you are agreeing that Whiteleys Retreat can collect, use and store your personal information which is in line with our Data Protection Policy and other relevant legislation.
I agree to help Whiteleys Retreat develop and grow as a charity by completing a Survey Monkey or handwritten Evaluation Form during our stay.

I have read the above and understand that by doing so all information given is accurate.

Name

This field is for validation purposes and should be left unchanged.

Get in touch

Whiteleys Retreat