* Indicates required information

Name of applicant (who will receive equipment/help):      

Address of above Applicant (including post code):      

Your Email address (so that we can confirm receipt of this application):    

Telephone No. of above applicant:      incl STD code

Date of birth of above applicant:         DD/MM/YYYY

Please describe the equipment or help required. Please provide manufacturer's details and product information:
 

Please provide at least two quotations for the equipment required:
Quote 1            Quote 2      

Have you made any other applications for funding from other charities?
If so who?
 

*Please provide full details of the Healthcare Professional Assessment and the child's condition.

 

How will funding from the Southend Sunflower Trust improve yours or your child's quality of life?
 

Has any other fundraising been done on your behalf?
 

If you are completing this form for the applicant, please include your details:

Your Name:    

Your Address:    

Relationship to applicant:    

Your Telephone:     incl STD code.

DECLARATION:  "I am happy for this information to be shared within the Southend Sunflower Trust and for a home visit if required".