Funding Application Form. Childs Details: First Name

Funding Application Form.
Childs Details:
First Name: ……………………………………………………….. Surname: …………………………………………………………………………………
Date of Birth: ……………………….
Parents/Carers Details:
Relationship to applicant: ………………………………………………………………………………..
First Name: ……………………………………………………….. Surname: ………………………………………………………………………………...
Address: ……………………………………………………………………………………………………………. Post Code: ………………………………...
Telephone No. ………………………………………………..
Email: ………………………………………………………………………………………
Please tell us of the child’s diagnosis and date of diagnosis:
………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
Please tell us how we can help your Child/Family at this time.
………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
Please provide details of the financial assistance required and costs.
………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………….
Have you made a previous application to MECP2 Duplication UK? Y/N
If yes, was your application successful, and please provide dates and details.
………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………….
Terms and Conditions:
Please provide a supporting letter from your consultant/Doctor with proof of your child’s diagnosis.
Please provide costings for items applying for.
You can only make one application within a 12 month period.
MECP2 Duplication UK will provide funding up to a maximum of £500 per application.
Items we will fund;





Therapies that will be beneficial
Sensory toys
Sensory lights
Specialist clothing
Travel to a specialist clinic or appointment
Items we will not fund;

Equipment
MECP2 Duplication UK processes all personal information about families in accordance with the requirements of
the Data Protection Act 1998.
A copy of the MECP2 Duplication UK Data Protection Policy can be supplied if requested.
What Happens next?
Please ensure that you have completed all sections of this application form, and submitted all relevant paperwork
in relation to the application.
This application will be considered in due course taking into account all information submitted, and we will
contact you notify that the application has been successful.
All details that I have are provided within this form are true and correct to the best of my knowledge. I understand
that failure to disclose full details could invalidate my application.
Name (Printed): ………………………………………………………………….. Signed: …………………………………………………………………
Date: …………………………………………….
Thankyou for completing this form, we will contact you to confirm receipt.
Registered charity number: SC044781
6 Welsh Place,
Saltcoats,
Ayrshire,
Scotland.
KA21 5TD.
TEL: 0784 9322 368
E-MAIL: [email protected]