Application Pack. Enriching the lives of children and young people who are disadvantaged either through poverty, disability or terminal illness.

Transcription

1 Applicatin Pack Enriching the lives f children and yung peple wh are disadvantaged either thrugh pverty, disability r terminal illness. The Bparan Charitable Trust Clmre Curt, 9 Clmre Rw, Birmingham. B3 2BJ Tel: The Bparan Charitable Trust is a cmpany limited by guarantee and is registered in England and Wales under cmpany Registered Charity

2 Applicatin Guidelines. We fully welcme all applicatins, hwever, please be aware that applicants must live within the UK and be aged 18 r under. Official written cnfirmatin by an independent prfessinal bdy will be required stating the applicant s cnditin r circumstance. This letter must be n cmpany letterhead, with cntact details. *Within the independent assessment they must state hw the child will directly benefit frm the request. Please find belw a list f things we DO NOT fund unless in exceptinal circumstances: Dnatins t ther charities Funeral Services Onging appeals Hlidays/ shrt break prgrammes Help with legal csts Reimbursements f funds already paid ut Repayment f lans Administratin r salary csts Accmmdatin csts Travelling csts Lease r purchase f cars Faith healing Dlphin therapy Music therapy Alternative therapy Warrantees Rm Hire Hme adaptatins/ renvatins Family memberships Carpets Garden equipment Fencing Cmputer cnsles e.g: Nintend Wii/Xbx/Play Statin PC s, Lap tps r tablets (unless designed fr children with special needs) Televisins/DVD players Prtable DVD/TV players Ht tubs Private Schl fees Sfas/ settees n medical bdy and face enhancements ABA Therapy currently under review This list is subject t change at any pint. The Bparan Charitable Trust reserves the right t decline an applicatin. Please te: *If successful, we d nt accept re-applicatin within 3 years. *We reserve the right t ffer a like fr like alternative prduct. *Occasinally we may request a re-assessment frm ur preferred supplier. *The Bparan Charitable Trust will nt pay directly int a persnal bank accunt. *The Bparan Charitable Trust des nt select equipment r treatments and nly prvides funding (Where apprved) Therefre accepts n liability fr any equipment supplied by third parties. The charity is nt a prvider r advisr in respect f equipment r any ther matter. The Trustees treat each applicatin as sensitively as pssible and reserve the right t request further infrmatin as and when needed.

3 Applicatin Frm Please read the Applicatin Guidelines befre filling ut this frm. Failure t fully cmplete this frm and prvide necessary dcuments may delay r invalidate yur applicatin. The Child Name f Child: Details f disability/illness/ circumstance: Date f Birth: Age: Hw lng have they had this cnditin? Name f the prfessinal supprting this applicatin* Telephne. f prfessinal supprting this applicatin* *(e.g: O.T/ scial wrker) The Family Name f Parents/Guardians: Pstal Address: Pstcde: D the Parents/Guardians c-habit? Yes If n, d yu share respnsibility fr the child? Yes If yes, please prvide a telephne number: Mbile : Telephne : Address: Names f ther dependents Age f dependents *FOR OFFICE USE ONLY.

4 Wishes & Dreams PLEASE NOTE: The Bparan Charitable Trust will nly grant requests t children aged 18 and under wh are resident in the UK and disadvantaged thrugh pverty, disability r terminal illness. Yur Request: Cst f item(s) requested, (please remember t attach qute if necessary)... Supplier... Please tell us mre abut the child his/her persnality & interests etc. and hw the request will benefit the child: Please cntinue n a separate sheet if necessary.

5 Financials In rder fr us t prcess yur applicatin, we require a breakdwn f the husehld s financial situatin. Please fill ut all the details belw. Failure t d s will result in yur applicatin nt being assessed. HOUSEHOLD INCOME 1st Parent/Guardian (net) Wage 2nd Parent/Guardian (net) Wage MONTHLY HOUSEHOLD EXPENDITURE Rent Mrtgage Disability Living Allwance Hi Maintenance/Child Supprt Disability Living Allwance Medium Childcare Disability Living Allwance Lw Secured Lans Carers' Allwance Gas Child Tax Credit Electricity Child Benefit Water Maintenance/Child Supprt Cuncil Tax Husing Benefit TV License Incme Supprt Telephne Cuncil Tax Benefit Mbile Phne Wrking Tax Credit Satellite/ Cable (Sky, Virgin) Jbseeker's Allwance Emplyment and Supprt Allwance Statutry Sick Pay Bradband/Internet Appliance Rentals/ HP/Cnditinal Sale Vehicle csts (e.g. tax, insurance, DLA Mtability) MONTHLY Maternity Allwance Statutry Maternity Pay Student Lan/ Grant Pensin Savings (ttal t date) Other* Fuel Public Transprt Sundries/ Fd Clthing/Ftwear Meals/Trips Leisure Activities/Memberships Student Curse Csts/Tuitin Fees Private Schl Fees Other* * Please specify any additinal surce f incme/expenditure. Failure t d s may invalidate yur applicatin. If yu are a Freign Natinal living r wrking within the UK, please prvide phtcpies f yur passprt and visa dcuments

6 Claims Have yu successfully applied t The Bparan Charitable Trust befre? Yes *Please nte: Previus successful applicants can nly re-apply after 3 years. Have yu applied t any ther charity fr yur current request? If s, please state: Charity Name Stage f Applicatin Have yu received items/grants frm any ther charities in previus mnths/years? If s, please state: Charity Name Item Awarded Legal Claims Have yu received any cmpensatin by way f legal claim in regards t yur child s cnditin? Yes If yes please specify amunt received:... When was this awarded?... Are yu currently pursuing a legal claim in regards t the child s cnditin? Yes If yes t either f the abve legal questins, please prvide details belw: please cntinue n a separate sheet if necessary...

7 Publicity Please tell us hw yu heard abut The Bparan Charitable Trust?... Help us, t help yu! The Bparan Charitable Trust hpes t help as many children as pssible and t d this we may want t use yur stry and phtgraphs n ur website t raise awareness fr ur cause. This way we can spread the wrd f the charity and encurage ther families t apply fr much needed help. Yes, I/we are willing t help with publicity, s ther families can benefit t., I/we are nt willing t help with publicity. Checklist A phtgraph / vide, if yu ticked yes t publicty, t supprt us in helping mre children. Fully cmpleted applicatin frm Written cnfirmatin f child s cnditin by a prfessinal independent bdy. E.g. Medical cnsultant r scial wrker. **(Minimum requirement fr wheelchair mst be cnfirmatin frm a dctr r higher level) Independent qute Agreement Please be aware The Bparan Charitable Trust may cntact yu at any pint t clarify the infrmatin prvided. DECLARATION: Althugh this applicatin can be cmpleted by a supprting member f the child, this must be signed by the parent/legal guardian t validate infrmatin given. All the details that I/we have prvided within this applicatin are crrect and true t the best f my knwledge. I fully understand that failure t disclse the crrect infrmatin will invalidate my applicatin. Signed:... Name (printed):... Date:.../.../... THANK YOU FOR COMPLETEING THIS FORM. PLEASE RETURN TO: The Bparan Charitable Trust. APPLICATIONS DEPARTMENT. 9, Clmre Curt, Clmre Rw Birmingham. B3 2BJ. If yu wuld like t speak t a member f staff in relatin t yur applicatin, please call: