Aids for Disabled People - Application Form

The Headley Trust administers a small grants programme which provides funding for practical aids for disabled people aged 16 and above. Grants are considered up to £2,500 to help disabled people purchase equipment which will help increase their mobility.

Applications can only be made by completing this form. Each applicant must be referred by a third party such as a registered charity, medical professional, social care worker or Citizens Advice Bureau. The referrer must specifically endorse the item(s) requested. Any professional assessments, supporting statements/letters, quotations are welcome. The application must be signed by the applicant (or carer on their behalf), the referring person and a senior colleague of the referring person.

Applications can be for, but not limited to, the following: specially adapted computer systems; communication aids, wheelchairs, electric scooters; and stair-lifts. Other items, recommended by a medical professional or social care worker, may be considered at the Trustees’ discretion, and are subject to the Conditions of the Award. In most cases, any grant award will be for no more than half the total cost of the equipment and will be released via the referring organisation when funds to meet the total cost have been raised. Grants will be available for one year from the date of approval.

PLEASE COMPLETE ALL PARTS OF THE FORM
Name of applicant / Surname / First Name
Address
Postcode / Phone
NATURE OF DISABILIY
Please give a brief description
Date of birth: / Age of applicant:
REFERRING ORGANISATION
Name of organisation/
practice
Name of referrer
Position
Department
Address and
Postcode
Telephone / Email
How long have you known the applicant?
Grant requested / Please give full details of the equipment you are applying for and a full statement in support of this specific need – please continue on a separate sheet if necessary. Please attach relevant supporting evidence i.e. quotes for items including delivery etc.
Grant amount requested (including VAT and delivery) / £ / Payble to
(see below)
Please note we can only make payments direct to a charitable organisation, the referring person’s practice, or CAB. We are unable to pay an individual or supplier (with the exception of Motability).
HOUSEHOLD INCOME - Please provide details of the benefits you are currently in receipt of (monthly)
Were you previously in receipt of DLA? / Yes/No
Are you in receipt of PIP? / Yes/NoAmount: £
Have you been turned down for PIP? / Yes/No
Please detail any other benefits you receive
TOTAL BENEFITS (monthly) / £
Other household income(monthly) / £
DATA PROTECTION
By signing the form the applicant agreesthat:
This application and any further information provided will be kept in our filing system (in paper and/or electronic form). Details of your application and any subsequent information will be recorded on our computer system, together with details of any subsequent correspondence and/or grants awarded. We may disclose your personal information as necessary to third parties who supply goods or services to applicants as part of the grant making process or similar. We may disclose your information to third parties where necessary to comply with applicable laws and regulations and/or for the purposes of obtaining professional advice (e.g. legal advice).
Signatures and AuthorisationTHREE SIGNATURES ARE REQUIRED
1 The applicant (or carer on their behalf)
2 The referring person (charity/healthcare professional/social worker)
3 The referring person’s senior colleague
By signing the form the applicant and referring person confirm that the information given is correct,that further information will be provided if requested, and that they accept the Conditions of the Award. The referring person confirms that they are responsible for ensuring that all criteria have been met, that the grant will only be used for the intended purpose, and that applicants are in receipt of all Statutory Benefits to which they are entitled before applying.
Applicant’s signature (or parent/carer on their behalf)
______PRINT FULL NAME ______Date ______
Referring person’s signature
______PRINT FULL NAME ______Date ______
Senior colleague’s signature
______PRINT FULL NAME ______Date ______
Senior colleague’s position (Please print)______

Conditions of the Award – The True Colours Trust Small Grants to Individuals

Applications will only be accepted from or on behalf of any young person aged 16 years and above who are on low incomes, and which are submitted via a ‘referrer’ as outlined below.

Applicants’ must have insufficient personal funds to purchase the equipment themselves. Applicants must provide the details of any benefits they receive and provide appropriate proof of this to the ‘referrer’ as outlined below.

The referring person must have seen evidence of these benefits. The referring person must ensure that all criteria have been met and that applicants are in receipt of all Statutory Benefits to which they are entitled before making the application. The referring person must be prepared to take responsibility for the application through to completion.

Any grant made must only be used for the purpose given in the application form and for which it is awarded. Grants cannot be awarded for items that have already been purchased, or bills that have been paid. The majority of awards are unlikely to exceed £2,500. Please note we cannot contribute to trips overseas, structural building works, private treatment or the purchase of vehicles.

The Headley Trust is governed by charity law and it is a condition of any grant made that the funding must be used for exclusively charitable purposes as part of the trust's broader goal of supporting those with disabilities.

Payment of the grant can only be made to a third party i.e. a charitable organisation, the referring person’s practice or CAB. We are unable to pay an individual or supplier (with the exception of Motability).

Grants are discretionary and the Trustees’ decision is final.

Please return the completed form to the address below or by email to:

The Headley Trust

The Peak

5 Wilton Road

LONDON SW1V1AP

The Headley Trust: Registered Charity No: 266620