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APPLICATION FORM

MENTAL HEALTH INDIVIDUAL EMPOWERMENT GRANT 2014 – 2015

The Individual Empowerment Grant exists to empower individuals with emotional or mental health issues to take up activities which help to promote a sense of wellbeing and positive mental health in order to reduce the stigma and impact of mental distress. Grants of up to £90 are available. If you need help completing this form or have any queries please let us know. You can call us on 01872 243532.

Your name:
Your address:
Postcode:
Phone no:
Email address:
Can we add you to our mailing list to receive our newsletters? Yes [ ] No[ ]
This grant is for people receiving help with emotional or mental health issues from a health professional. Please tell us the name of the health professional you see:
What is their job title?
How much money are you applying for? £
Please provide details of costs on p2 and send proof of these with this application
If successful, the money can be paid straight into your bank account. If you do not have a bank or building society account, someone else can receive the money for you so please give us their details instead.
Name of bank/building society (e.g. HSBC):
What is the name on the account (e.g. Jane Bloggs):
Account number:
Sort code:

Please tell us exactly how much the item or activity costs?
We need this information to process your application. If you cannot do this, please give us a call to discuss we may be able to help.

Please check the list of items we cannot award a grant for at the end of this form to make sure your application is eligible. Multiple items must be part of the same activity (e.g. bike + helmet).

ITEM/ACTIVITY
e.g. gym membership / COST £
£80
Is this money for a college course? Yes [ ] No [ ]
If yes, when does this college course start?

Please tell us how the item(s) or activity will help improve your emotional or mental wellbeing

Additional supporting information

Please write here any information that will help us in assessing your application, e.g. more information about what you intend to use the grant for and how it will help you.

Please tick ALL to confirm the following:

[ ]I live permanently in Cornwall or the Isles of Scilly.

[ ]I am aged 16 years or over.

[ ]I have not received a grant from you in the last 18 months (if you’re not sure, please call us to check)

[ ]I am receiving treatment from a Health Professional (e.g. GP, nurse, counsellor, etc) for my emotional or mental health.

[ ]The item(s) I am requesting a grant for has/have not yet been paid for.

[ ]I am including proof of how much the item(s) costs (We need this information to process your application. If you cannot do this, please give us a call to discuss – we may be able to help).

[ ]I understand that if I am given a grant, I will only use it for the item or activity stated in my application form. If I need to use the money for something else, I understand I must get permission from CRCC first.

[ ]I agree to complete a feedback report on how I spent the grant and how it has helped me and agree to send in all receipts within 3 months of buying the item or completing the activity. If I cannot do this, I understand I must contact CRCC explaining why.

[ ]I confirm all the information provided in this application is true and accurate to the best of my knowledge.

Full name:
Date:

What we need from you

  • Evidence of what the item(s)/activity is and how much it/they cost. This is essential.
  • A breakdown of costs, particularly if you are applying for money for more than one item. Please use page 2 of this form to do this.
  • If you need to spend the money on an item or activity you haven’t mentioned in this application, please get permission from us to do this first.
  • Copies of receipts or invoices must be sent to us as soon as possible. Failure to return receipts may result in a request for you to return the grant to us. Please call us if you have any concerns about this.
  • Please tell us how this grant has been of benefit to you; we’d love to hear about it. A feedback form will be sent to you and it is essential that you return this.

Next Steps

When you are ready to send the form to us, please email to

Please take a copy of this completed form for your own records, you may need to refer to it in the event we have a query.

If you need to call us, our number is: 01872 243532

Data Protection

This information will be stored electronically and will remain confidential to CRCC. We will seek your written agreement before using it for any purpose other than that described herein (such as use by a third party).

What we cannot award grants for:

  • Travel expenses.
  • College courses that have already started and have a fixed start date.
  • Where total costs exceed £200.
  • Anyone who has already received this grant from us in the last 18 months.
  • Clothing, furniture, rent, domestic appliances or household repairs.
  • Medical treatment.
  • Business supplies, e.g. office furniture.
  • Holidays or family contact.
  • Driving lessons, vehicle tax, MOTs or car repairs.
  • Veterinary fees.
  • Food or drink items.
  • Requests to fund several items that are not related.
  • Weapons, e.g. swords, guns, etc.
  • Anyone not experiencing emotional or mental distress. Where other health problems are indicated (e.g. drug/alcohol issues, physical health issues), we will require supporting evidence to show that your emotional or mental distress is the main issue, e.g. a letter from a health professional.
  • Debt relief.

EQUAL OPPORTUNTIES MONITORING FORM
STRICTLY CONFIDENTIAL
Cornwall Rural Community Council is committed to providing equal opportunities. With this in mind, we hope that you will assist us in monitoring by completing this anonymous sheet and returning it with your application form.
This information is used for the pur poses of monitoring our equal opportunities policy and will also be used to inform NHS Kernow how far our services represent the population of Cornwall
GENDER
Male [ ] Female [ ] Other [ ]
AGE
16-20 years [ ] 21-30 years [ ] 31-40 years [ ] 41-50 years [ ]
51-60 years [ ] 61-64 years [ ] 65 years or over [ ]
ETHNIC GROUP
A: White
British [ ] Irish [ ] White other (please state)
B: Mixed
White & Black Caribbean [ ] White & Black African [ ] White & Asian [ ]
Mixed other (please state)
C: Asian or Asian British
Indian [ ] Pakistani [ ] Bangladeshi [ ] Asian other (please state)
D: Black or Black British
Caribbean [ ] African [ ] Black other (please state)
E: Chinese or other ethnic group
Chinese [ ] Other (please state)
Do not wish to disclose [ ]
DISABILITY
Do you consider yourself to have a disability? If yes, please tick the appropriate box(es)
Mobility impaired [ ] Hearing impaired [ ] Mental health difficulties [ ]
Sight impaired [ ] Learning difficulties [ ]

Page 1 CRCC charity number 1087550 Individual Empowerment Grant Application