Helping Hands a Little Hand

Helping Hands‘a little hand’

application form

WellChild is the national charity for children and young people with serious illnesses or complex care needs.
Helping Hands‘a little hand’works with teams of volunteers from local companies to install one off solutions to the problems families face with their garden or home.

We want to help as many families as possible, but limited resources mean we are unable to help everyone that we would like to. The application process helps us to decide which projects we can accept and so it is important that you give as much information as possible on the form and provide all the information requested to help us with this decision.

Eligibility

The child or young person must be aged between one and 18 years old and have an enduring serious illness, or a severe disability with complex care needs.

Your answers must show that the child or young person’s needs have a significant impact on them and the family’s choices and opportunity to enjoy ordinary life. The amount of planning and support needed to meet their needs must be much greater than that usually required to meet the needs of children and young people.

Help with completing this form

If you have any questions about completing this form then please contact the Helping Hands team on 01242 530007

The application process

Step 1:Complete the application form with as much information as possible.

Step 2:Take photographs to support the application. We can NOT consider applications without clear and suitable colour photographs. Use the guidance notes at the end of the application to help you.

Step 3:Post the completed application to us at WellChild, 16 Royal Crescent, Cheltenham, GL50 3DA, or email a copy to . Please give the child or young person’s name in the subject line.

Step 4:We will acknowledge that we have received the application form by email or letter. We may need to ring you to check the information that has been given.

Step 5:A committee will consider the application at their next meeting. Meetings are normally held in January, May and September. At these meetings the committee will decide if one of the Helping Hands team should visit you/the family to find out more about the help that is wanted. This visit is not an agreement to take on the project.

Step 6:A visit will be arranged within four months of the committee meeting. At the visit we will explain more about WellChild, ask some questions about help needed and take measurements and additional photographs. We may ask if we can meet the child or young person.

Step 7:The committee meets again to decide if the project can be accepted or not. These meetings are held in January, May & September. We will let you know as soon as possible after the meeting if we are able to help.

Child or young person’s details

First Name:………………………………….Surname:………………………………….

Date of Birth:………………………………….Age:...... FemaleMale

Address:………………………………………………………………………………………...
......

Postcode:………………………………….

Your contact details

Title: (please tick)Mr  Mrs  Miss  Ms Other:………………......

First Name:………………………………….Surname:………………………………….

Telephone:………………………………….

Mobile: ………………………………….

Email:………………………………….

Your relationship to the child/young person: ………………………………….

Your details are held securely in accordance with the Data Protection Act 1998.

How did you hear about WellChild Helping Hands? ……………………………….

Main carer for the child/young person?

Title:(please tick)Mr  Mrs  Miss  Ms Other:………………......

First Name:………………………………….Surname:………………………………….

Telephone:………………………………….

Mobile: ………………………………….

Email:………………………………….

Your relationship to the child/young person: ………………………………….

Child or young person’s home
Is the child/young person living at the above address permanently? Yes No 

Please list all of the people living at this address.

Name / Relationship to child / Age (if under 18 years)

Does the child/young person share a bedroom?

Yes No If yes, who do they share with? ……………………………….

Information about the child/young person

What condition/diagnosis does the child/young person have?

......

When were they diagnosed? …………………………………………………………..

Tell us how their condition affects them on a day to day basis:

......

Please tell us if the child/young person has any behaviours that can affect their safety:

For example: do they put things in their mouth or lack an understanding of danger?

......

Please give details of any treatment they are receiving and/or professionals involved in their care:

......

Equipment used:

Wheelchair  Walking frame  Oxygen  Hearing Aids  Hoist 

Other: ………………………………………………………………………………………...

Is the child/young person receiving any additional support if they attend Nursery/School or College?

Yes  No 

......

Please give details of any communication difficulties the child has:

......

Project information

The Helping Hands ‘a little hand’programme offers a solution to specific problems or needs. Please tick which solution you would like to apply for:

Medical sundries storage solution (Internal) –

Shelves and wardrobe solutions

There must be a suitable space for them to be fitted.
There must be a real storage need as a result of the medical sundries required for the child’s care.

Medical sundries storage solution (External) –

Insulated sheds (6’ x 6’ max)

There must be a flat and clear area where the shed can be sited.
There must be a real storage need as a result of the medical sundries required for the child’s care.

Bounce and motion stimulation –

Sunken trampolines

There must be a flat space free from pipes and drains for a sunken trampoline. It will be a maximum 8ft wide.
This is intended for children with limited mobility that would benefit from the sensation of bouncing/rebound therapy.

Access via wheelchair friendly flooring -

Fake turf

The spaces must be generally level and no larger than 40 metres square.
This is for children who require a soft level surface, perhaps due to mobility or sensory needs.

Sensory stimulation area –

Sensory additions(For example: murals, planters, mirrors and play tables) 

There must be an area that is already accessible to the child/young person.
We do not fund expensive ‘shop brought’ sensory equipment.
The child must require sensory stimulation that cannot currently be provided at home.

Security –

Installation of fencing (timber panel fencing) 

Must be no longer than 30metres in length with clear access to install it.
It must be for the benefit of the child, for example for their safety or privacy.

Project information continued

Please give details extra details you think we need to know:

......

Why is the selection you have made needed?

......

How will the child/young person benefit if the changes are made?

......

Why has the work not been completed before now?

......

About the property

How long have you lived at the property:………(years)

Are you the owner of the property you live in? Yes  No 

If not, then tell us who owns the property? ......

For example: local council, housing association, private landlord

Name: ………………………………………………………………………………………...

Address: …………………………………………………………………………………………

......

Postcode:………………………………….

Telephone:………………………………….

Email:………………………………….

Website:………………………………….

Has the property owner been asked to complete the work? Yes  No 

If yes, what was their response?
......

......

If no, what was the reason that they were not asked?

......

We will need to contact the property owner to ask them to agree to any work that we want to do. If they do not agree we will have to decline the project.

Parent/Guardian Declaration

Declaration

I/We confirm that all information supplied to WellChild in connection with this application is true and correct.

I/We confirm that you may contact the Health or Social Care Professional who completed the application support section or the person who completed the form, for additional information if needed.

If you complete the application electronically please print your name below to confirm youragreement.

Parent(s)/guardian(s)

Signature: ………………………………….………………………………….

Print Name(s):………………………………….………………………………….

Date: ………………………………….………………………………….

Wherever possible WellChild likes to take into account the opinions of the children and young people it supports. If your child is able to understand and confirm their agreement to this application please ask them to sign below.

Childs signature:………………………………….Date:………………………………….

WellChild will keep the information on this form securely and in confidence. By signing the form you are consenting to WellChild using the information and personal data it contains - or which is supplied by third parties or nominators - in accordance with the Data Protection Act 1998.
Any sharing of your personal data will be consistent with our obligations under the Act, and it will be kept no longer than necessary. Information about your rights under the Act, including your right to see personal data which WellChild holds about you, is available from the Information Commissioner at

We would like to keep you informed about the work that we do at WellChild. Please tick the box if you do not wish to receive this.

Application support

The application must be supported by a Health, or Social Care professional, who is involved in the care of the child/young person.

Contact details

Title:(please tick) Mr  Mrs  Miss  Ms Other:………………………………….

First Name:………………………………….Surname:………………………………….

Job title: ………………………………….

Address:………………………………………………………………………………………...

......

Telephone:………………………………….

Mobile:………………………………….

Email: ………………………………….

I can confirm that to the best of my knowledge the child/young person has the following condition or diagnosis: ......

......

I can confirm that the proposed Helping Hands project will benefit the child in the following ways:

......

If I have any doubts or concerns regarding the Helping Hands project I shall communicate them in writing to the parent(s)/guardian(s) and to WellChild as soon as possible.

Signed:………………………………………Date:……………………………………….

WellChild will keep the information on this form securely and in confidence. By signing the form you are consenting to WellChild using the information and personal data it contains - or which is supplied by third parties or nominators - in accordance with the Data Protection Act 1998. Any sharing of your personal data will be consistent with our obligations under the Act, and it will be kept no longer than necessary. Information about your rights under the Act, including your right to see personal data which WellChild holds about you, is available from the Information Commissioner at

We would like to keep you informed about the work that we do at WellChild. Please tick the box if you do not wish to receive this.

Photography guidance notes

The committee have to make an initial decision about the application without a visit being made to the property. It is really important that the photos provided give them a good understanding of whatthe garden/bedroom looks like now.

Below is a diagram of how the photos should be taken in a standard shaped garden or bedroom. Please do not point the camera at the floor. Try to take shots that give a good idea of scale and proportions of the area. Please provide colour photos.

For gardens please provide a shot that shows how the garden is accessed and also provide photos of any areas that need highlighting, for example, a section of particularly unsafe fencing.

Children and young people’s photographs

It is helpful for the committee to have a picture of the child or young person to put a face to the name but it is not essential. We would always ask you for permission before using the photograph for any other reason. If you are happy to provide one please make sure that the photograph is suitable for us to use. If the application is accepted and agreement is given then it will be used to promote the project to companies. Photos must be clear and please make sure that the child or young person is adequately clothed and, where possible, looking into the camera.

Photos can be posted to us with the application, emailed to , or sent to us using a free file sharing website, for example Please provide the child or young person’s name in the subject line.