AIDS FOR DISABLED PEOPLE APPLICATION FORM THE HEADLEY

PLEASE COMPLETE ALL PARTS OF THE FORM

Name of applicant

Surname

First Name

Address

Postcode

Phone

NATURE OF DISABILIY

Please give a brief description

Date of birth:

Age of applicant:

REFERRING ORGANISATION

Name of organisation/

practice

Name of referrer

Position

Department

Address and

Postcode

Telephone

Email

How long have you known the applicant?

Grant requested

Please give full details of the equipment you are applying for and a full statement in support of this specific need – please continue on a separate sheet if necessary. Please attach relevant supporting evidence i.e. quotes for items including delivery etc.

Grant amount requested (including VAT and delivery)

£

Payble to

(see below)

Please note payments are generally made direct to a charitable organisation, the referring person’s practice, or CAB. We occasionally arrange payments via the supplier subject to receiving a suitable quote. We are unable to pay an individual directly.

HOUSEHOLD INCOME - Please provide details of the benefits you are currently in receipt of (monthly)

Were you previously in receipt of DLA?

Yes/No

Are you in receipt of PIP?

Yes/No Amount: £

Have you been turned down for PIP?

Yes/No

Within the last year, have you received Working Tax Credit or Pension Tax Credit?

Please detail any other benefits you receive

TOTAL BENEFITS (monthly)

£

Other household income (monthly)

£

DATA PROTECTION

By signing the form the applicant agrees that:

This application and any further information provided will be kept in our filing system (in paper and/or electronic form). Details of your application and any subsequent information will be recorded on our computer system, together with details of any subsequent correspondence and/or grants awarded. We may disclose your personal information as necessary to third parties who supply goods or services to applicants as part of the grant making process or similar. We may disclose your information to third parties where necessary to comply with applicable laws and regulations and/or for the purposes of obtaining professional advice (e.g. legal advice).

Signatures and Authorisation THREE SIGNATURES ARE REQUIRED

1 The applicant (or carer on their behalf)

2 The referring person (charity/healthcare professional/social worker)

3 The referring person’s senior colleague

By signing the form the applicant and referring person confirm that the information given is correct, that further information will be provided if requested, and that they accept the Conditions of the Award. The referring person confirms that they are responsible for ensuring that all criteria have been met, that the grant will only be used for the intended purpose, and that applicants are in receipt of all Statutory Benefits to which they are entitled before applying.

Applicant’s signature (or parent/carer on their behalf)

________________________________________________ PRINT FULL NAME ___________________________________ Date _____________

Referring person’s signature

________________________________________________ PRINT FULL NAME ___________________________________ Date ______________

Senior colleague’s signature

________________________________________________ PRINT FULL NAME __________________________________ Date ________________

Senior colleague’s position (Please print) ______________________________________________________