Individual Grant Application On-line Form

Individual Grant Application Form

Please fill in all the fields marked *

Carers Details
Name*
Address*
Postcode*
Tel No.*
Mobile No.*
Email*
Enter Email Confirm Email
Date of Birth*
DD slash MM slash YYYY
How long have you been a carer?*
How many hours per week do you care for someone?*
Who lives with you?*
Do you or anyone else in your household work? Please describe*
Please tell us about your financial circumstances. Do you receive any benefits or have any savings?*
If yes, please describe. The fact that you work and may not be receiving benefits, or have some savings does not mean we will not help, but we ask you to be open with us about your situation.
About the person cared for
Name*
Address*
Date of Birth*
DD slash MM slash YYYY
Their relationship to you?*
Please describe their illness or disability*
What help do they receive from Social Services or other agencies?*
Information about the grant you are applying for
Have you received a grant from us before? If yes, please give details. This does not mean that we won’t be able help you again*
Please tell us how you heard about The Leonardo Trust? e.g. Social Worker, G.P, advert, internet etc.*
Please tell us in as much detail as possible what you are asking us to fund and why this would help you?*
Please tell us if your caring responsibilities have impacted upon your physical or mental health etc. If you are applying for a holiday or short break, please tell us where you would like to go? Who would go with you? When and for how long? Is alternative care being provided for the person you care for? Please attach an estimate or quotation where possible.
What is the total amount of grant you are applying for?*
Are you or anyone else able to contribute to the cost? Please describe and state amount*
The trustees regret we are unable to reimburse costs already paid or anything that has been booked, contracted for or reserved prior to our agreement to fund/part-fund the cost. Many of the grants we award are under £300 and we may ask you to contribute towards the cost of an item.
Consent*
I agree to the privacy policy.
I understand that all information supplied on this application form will be kept strictly confidential and will only be used for the purpose of selection and administration. The information I have given in this application is, to the best of my knowledge, true and accurate. I accept that any false or misleading statements may be sufficient cause for rejecting my application. A copy of our Grant Making Policy is available on our website, www.leonardotrust.org or alternatively from our Broadstone office.
Professional Endorsement
Please provide the details of a social care / healthcare / educational professional / support worker or GP who can confirm your status as a carer.
Name*
Agency Name*
Address*
Postcode*
Tel No.*
Mobile No.*
Email*
Enter Email Confirm Email
Your Role*
How long have you known the applicant and in what capacity?*
Do you support this application?*
Yes or No
Please outline how this request for a grant would help the applicant? If you do not support the application, please explain why?*
The information I have supplied above is, to the best of my knowledge, true and accurate.*

If you have any difficulties in completing this form or would like to discuss your application, please telephone 01202 698325 or email info@leonardotrust.org

Individual Grant Application Form

Carers Details

About the person cared for

Information about the grant you are applying for

Professional Endorsement