Application for Hospital Stay Grant

Section 1 : Applicant Information

Applicant Type

GMC/NMC/HCPC Registration

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 Address & Admission Dates

Child's Health Diagnosis

Child's School or Nursery

As part of the application process we need to verify the child's hospital stay 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.

If you enter just 'any doctor' or 'any nurse' your application may be declined. We need a named professional to be able to verify your application.

Verifier Type

Verifier Name

Verifier Phone

Verifier Email

Section 3 : Payment Details

Once we have verified and authorised the application for support we would like to get payment to support the child's family as soon as possible so we make payment to the parents or legal guardian's bank account by direct transfer. We cannot make payment to a bank account that is not in a parent or legal guardians name. We also cannot make payment into pre-payment card accounts, Cashplus, Tide, Revolut, ThinkMoney, Suits Me or any other account where there is a high risk of potential fraud.

Please ensure the bank details are correct as the charity is not liable for incorrect bank details being supplied on the application form.

Please note: Successful applicants will be required to complete a Payment Acceptance Form (PAF), failure to return this to the charity will result in the charity asking for funds to be returned.

Account Holder Name

Account Number

Sort Code

Bank Name

Branch

Have you double checked the bank details to confirm they're correct?

Payment will be made into the account details supplied on this page on acceptance of an award.

Confirmed Correct

Yes

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 be made directly to the bank details that have supplied and that the charity is not responsible if I have supplied incorrect bank details. I further understand that if I do not return the Payment Acceptance Form, I will be required to return the Hospital Grant payment back to the charity.

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 : Payment Details

Section 4 : Confirmation

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

Horley Green Works
Horley Green Road
Halifax HX3 6AS

Registered Charity Number 1146884 & Limited by Guarantee Number 10650385

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