Application for 50:50 Grant

Section 1 : Applicant Information

Applicant Type

GMC/NMC/HCPC Registration

Application Urgency

Title

First Name

Surname

Landline Phone

Mobile Phone

Contact Address

County

Postcode

Section 2 : About The Child

Child's First Name

Child's Surname

Child's Gender

Child's DOB

Child's Address

Child's Parents/Legal Guardian

Hospital or Hospice Address

Child's Health Diagnosis

Child's School or Nursery

As part of the application process we need to verify the application with a medical professional, a key worker or social worker. Please supply details of who you would like us to contact to verify your application.

Verifier Type

Verifier Name

Verifier Phone

Verifier Email

Section 3 : Grant Breakdown

Please provide further details of the items you would like to apply for. Please remember our maximum award is £500 towards a grant of £1000 or more. We can consider applications for over £1000, but our maximum contribution would be £500.

If you are making an application to another chairty to help fund your items, please let us know. We are are happy to liaise with other organisations so we can support the child as quickly as possible.

To help support beneficiaries on a low income, we are happy to pay awards of £100 or under in full for successful applicants.

Total Cost of Items

Amount Requested

List of Items

Supplier Details

What Need To This Support?

Do you have any funding in place?

Yes

Applications Made

Funding Details

Please upload any documents to support your application, this could be your DLA/PIP award letter, medical letters or reports and any invoices or order forms. Please note that we cannot accept photographs of letters/forms as evidence.

This should be uploaded as one PDF document.

Support File upload (1 PDF only)

Choose File

Section 4 : Confirmation

I confirm the information I have supplied is true and correct and understand it will be processed in line with the application terms and conditions. I understand that providing false or misleading information will result in the application being declined and information may be shared with the police and fraud prevention agencies.

Both the applicant and the parents and/or the legal guardian of the named child consent to the charity using the supplied information in line with GDPR regulations to store and use the data in connection with verifying and processing the application and provide the services of the charity.

Both the applicant and the parents and/or legal guardian of the named child consent to members or agents of the charity contacting Outside Agencies and for them to release sensitive data which will include names, dates of birth, medical conditions and illness details and hospital stays, this is only for the reason of decision making in relation to this support application.

As Applicant, I confirm that I understand that if my application for the Child is successful that payment will usually be made directly to the supplier and the remaining funds will need to be in place before any items are ordered or reserved.

Applicant Signature

Please use your mouse or finger to sign your usual signature.

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Section 1 : Applicant Information

Section 2 : About The Child

Section 3 : Grant Breakdown

Section 4 : Confirmation

Yorkshire Children’s Trust – a local charity, helping local children

Registered Charity Number 1146884
YCT House • 70 Commercial Street • Halifax • HX1 2JE