APPLICATION FORMFOR AN INDIVIDUAL SPORTS WHEELCHAIR

Patron: Dame Tanni Grey-Thompson DBE

Please return your completed form to:

Any attachments that cannot be sent by email must be sent to:

Grants Executive, Lord’s Taverners, 90 Chancery Lane, London, WC2A 1EU

This application should be completed by the individual requiring a sports wheelchair. If the applicant is under the age of 18 years then the form must be completed by a parent or guardian.

Please write clearly in block capitals using black ink or type.

ALL SECTIONS OF THIS APPLICATION FORM MUST BE COMPLETED

SECTION 1 – Contact details of Applicant

Name of person making the application:
Contact Address:
Postcode: / Relationship to wheelchair user:
Telephone Day: / Telephone Evening:
Mobile: / Email Address:
Name of individual who will benefit from wheelchair:
Address of Individual if different from above:
Postcode: / Date of Birth:
Age in years:
Telephone Day: / Email Address
Please provide details of the individual’s disability and when it was diagnosed.

SECTION 2 – Sporting Activity

Please give a resume of the individuals sports participation and achievements to date:
For what sport is the chair required? / How long have they been playing sport?
What sports club do they belong to?
How often do they attend training sessions? / How long are the training sessions?
To what standard do they play?

SECTION 3 – Sports Wheelchair Options

Details of the schemes offered by the Lord’s Taverners are shown below. Please tick the option that meets your needs.

Multi-sports wheelchair
The chairs are supplied by RGK Wheelchairs who offer a standard specification based on a Moly Quattro (basketball), Grand Slam (tennis) and multi-sports frame. The only options offered are a choice of colour and size. The applicant is required to make a self-help contribution of £350 towards the cost of the wheelchair.
□I would like to apply for a multi-sports wheelchair and understand that I am required to make a contribution of £350.
□I have my self-help contribution in place.
Bespoke wheelchair
This scheme is aimed at those individuals who are playing at a higher standard and/or require a personalised specification.
The Lord’s Taverners will consider providing supportof up to 50% of the total cost to a maximum level of £1,500.
A quote from a recognised supplier must be attached. Our financial support will be paid directly to the supplier.
□I would like to apply for support towards the cost of a bespoke wheelchair.
□Please confirm you have attached a quotation for the wheelchair.
Total cost of wheelchair? ……………………..Support requested from Lord’s Taverners? ……………….
Do you have the outstanding funding in place? Yes / No
Please outline why you are unable to fund the cost of the chair directly?
Have you approached your Local Authority or applied to another source for assistance with funding? If yes please give details, including date of application and outcome:

SECTION 4 –General – Please complete all relevant questions

Why are you applying for a sports wheelchair?
What significant impact do you think having the sports wheelchair will make to the individual?
Where will the wheelchair be stored?
Have you applied to the Lord’s Taverners before? Yes / No / Was your application successful?Yes / No
If Yes, what was the date(s) of your application(s)? / How much did you receive?
How often has the sports wheelchair been used?
What is going to happen to the old sports wheelchair?

SECTION 5 – Referees

Please provide details of two people who we may contact to obtain a reference to support your application. One must be a coach at the sports club and the second could be school, family doctor or similar.

Referee One

Name:
Contact Address:
Postcode: / Relationship to wheelchair user:
Telephone Day: / Telephone Evening:
Mobile: / Email Address:

Referee Two

Name:
Contact Address:
Postcode: / Relationship to wheelchair user:
Telephone Day: / Telephone Evening:
Mobile: / Email Address:

SECTION 6– Presentation & Photographs

Should your application be successful, would you agree to a presentation?Yes / No
Are you agreeable to have photographs taken and for the Lord’s Taverners to use them for publicity purposes? Yes / No

SECTION 7– Confirmation and Signature

Please provide any additional information to support your application on no more than one sheet of A4.

I hereby agree that to our knowledge the above information is correct and that we adhere to the guidelines set out by the Lord’s Taverners.

Please make sure that you submit your application electronically.

Signature: / Relationship to Child:
Print Name: / Date:

Registered Charity: 306054 / Company Number: 582579

Updated: July 2014