Funding

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Child's details...

First Name:

Surname:

D.O.B:

Parents/Guardians details...

First Name:

Surname:

House number/name and street:

Address line 2:

City:

Postcode:

Home telephone:

Mobile telephone:

Email:

Occupation:

Relationship to child:

Occupational Therapist (OT) or Social Worker details

First Name:

Surname:

Institution/Company:

House number/name and street:

Address line 2:

City:

Postcode:

Work telephone:

Mobile telephone:

Email:

Equipment/support required

Brief description:

How will this equipment/support benefit the child?:

Cost (£):

Supplier name (we may request a written quotation):

Supplier telephone:

Part-Funding

Have the family any means of part-funding, by way of a personal contribution or from any funds raised through events, sponsorship, parties, etc., and if so, how much?:

Have any other charities/organisations been asked to help fund and if so, who and how much?:

Additional information / comments:

If your application is successful do we have your permission to use your photos for testimonial & publicity literature (web, email, flyers, etc.)?:
 Yes No

Do you give permission for PhysCap and their corporate sponsors to contact you with future events, promotions and offers?:
 Yes No

How did you hear about PhysCap?:

Have you ever applied for funding to PhysCap before this application?:
 Yes No

For security reasons, please type the following code, including CAPS if applicable.
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If your application is successful, please may we use your story to promote the charity, so we can help more children?
 Yes No