Web viewWord of mouth. Other Charity. Internet : Other : ... £50,001-£69,999. £25,001-£30,000. £70,000+ Part 5 – Grant form completed by: Title. First Name

VICTA5 Douglas House

32-34 Simpson RoadFenny Stratford

Milton KeynesMK1 1BA

Tel: 01908 240831Email: [email protected]

Grant Application Form

Please complete as fully as possible Please note VICTA cannot provide items for use in school/college If returning the form by post, it should be signed, if being sent via e-email the

applicant/parent/ guardian should tick the box to indicate that they agree to the terms and conditions

Part 1 – About the applicant

Title First Name SurnameDate of Birth Age SexAddress:

Postcode:Home Tel. No. Mobile/Work No. Email

Name of Parent/Guardian (if under 18)Title First Name SurnameHome Tel. No. (if different from above)

Mobile/Work No. (if different from above)

Email (if different from above)

Eye Condition:

Any Other Conditions:

Would the applicant describe himself/herself as blind or partially sighted? (add X in the appropriate box)

Blind/Severely Sight Impaired Partially Sighted/Sight ImpairedIs the applicant registered for this visual impairment? (add X in the appropriate box)

Yes – date registered: No

If the applicant is registered, please include a copy of the registration document /card or if not registered, a letter from an Ophthalmologist confirming visual acuity.

Your application will not be processed without these documents.

School/College/University/Employment details of applicantName: Date Started: Date of Leaving :Address:

Postcode:VICTA CHILDREN LTD (a company limited by guarantee)

Company No: 3424608 Charity No: 1065029Trustees: Richard Lewis (Chairman), Estella Brown, Matthew Clark, Pamela Lewis, Elizabeth Richards, Chris Sprenger

Patron: Michel Roux Jr, Mardy Smith OBE

mailto:[email protected]





Local LEA, if still in education:

VICTA CHILDREN LTD (a company limited by guarantee) Company No: 3424608 Charity No: 1065029

Trustees: Richard Lewis (Chairman), Estella Brown, Matthew Clark, Pamela Lewis, Elizabeth Richards, Chris SprengerPatron: Michel Roux Jr, Mardy Smith OBE






Part 2 – Contact Details of Supporter

Title: First Name: Surname:

Profession/Job Title:

Work Telephone No.: Mobile No.: Email:

Work Address:

Postcode:In what capacity do you know the applicant and for how long have you know them?

Please provide a brief statement outlining the items required and why? Please continue on a separate sheet if needed.








Part 3 – Grant Information

Item Purpose of request Cost Price quoted from

Example:Magnifying Glass

To enable the applicant to read books £20.00 RNIB

Total Cost £Does the applicant use this equipment at school? (add X in the appropriate box)

Yes No

If not, what experience does the applicant have of using the equipment?








Part 4 – Finance

Please note that if your application is successful, you will be then be asked to make a financial contribution, at the Trustees’ discretion, towards the purchase of the equipment.

How much would you like to contribute towards this equipment? (Please note this may differ from the final amount requested by the Trustees.)Have you asked any other grant giving organisation for assistance with purchasing this item?

Name of Organisation Contact Number Support Received

Please provide details of any

support approved or date sent if pending

If you have applied to more than three organisations’ please list the rest on an additional sheet.Have you applied to VICTA in the past? (add X in the appropriate box)

Yes NoIf yes, please state the reference number and equipment requested

If No, please specify how you were introduced to VICTA (add X in the appropriate box)

Sight Village VI Teacher/ProfessionalWord of mouth Other CharityInternet : Other :

Have you applied to any charities, trusts or organisation for a similar item in the past five years?If Yes, please specify below:Organisation applied

to: Item applied for Date Support received








Are the family in receipt of benefits? (add X in the appropriate box) Yes – please state the benefits below No

What is the annual household income? (add X in the appropriate box)

Under £15,000 £30,001-£40,000

£15,001-£20,000 £40,001-£50,000

£20,001-£25,000 £50,001-£69,999

£25,001-£30,000 £70,000+

Part 5 – Grant form completed by:

Title First Name Surname:

Relationship to applicant:

How would you prefer to receive correspondence regarding the grant application? (add X in the appropriate box)

Post EmailVICTA CHILDREN LTD (a company limited by guarantee)








Part 6 – Declaration

This section must be signed by the applicant if they are 18 and over or by the parent/guardian if under 18.

I declare that the information provided on this form is complete and correct. I understand that information given will be held under the terms of the Data Protection Act.

I agree that VICTA can use the information I have supplied on this form, including details about my sight condition in order to deal with my grant application and provide me with information of other support services.

I agree that VICTA may discuss the information given on this form with other organisations who may be asked to provide relevant information, goods and services or assist with this grant.

I have completed the required forms and enclose copies of the requested paperwork.

I understand that this form is a request for a grant to be considered by the Trustees of VICTA and that the Trustees decision is final.

I understand that if funding is approved VICTA is not required to provide payment towards the upkeep of this equipment, including replacement, maintenance, insurance, extended warranties etc. Any such undertaking shall be the responsibility of the beneficiary, parent, legal guardian or other.

I agree that if funding is approved and at a later date the recipient no longer requires this equipment I promise to inform VICTA of this so they can decide if the equipment should be passed on to another young person in need of such equipment.

I consent to have any photographs/thank you letters that I send to the charity used for publicity purposes, including online and in printed documents

By signing below you are confirming you have read, understand and agree to the above declaration.

Print Name:

Signature: Date:

Relationship to applicant:

If you have any queries about this form please contact us on VICTA CHILDREN LTD (a company limited by guarantee)








01908 240831 or [email protected]

Please return completed form, along with a copy of registration documents to:

VICTA Children Ltd, 5 Douglas House, 32-34 Simpson Road, Fenny Stratford, Milton Keynes, MK1 1BA





Documents

Web viewWord of mouth. Other Charity. Internet : Other : ... £50,001-£69,999. £25,001-£30,000. £70,000+ Part 5 – Grant form completed by: Title. First Name