Parents/Guardians details...

First Name:

Surname:

House number/name and street:

Address line 2:

City:

Postcode:

Home telephone:

Mobile telephone:

Email:

Occupation:

Relationship to child:

MotherFatherStep-parentLegal Guardian

Number of children aged 17 and under living in the household and their ages:

Have you been living in the UK for the last 6 months:

YesNo

If no, give details:

I am British:

YesNo

If you are not British – do you have a current legal residency in the UK and
have recourse to public funds:

YesNo

If yes please send confirmation of your residential status with this Application

Do you require an interpreter to talk about your application? If yes, in which language?
about your application

Alternatively can you give details of someone who can speak on your behalf:

Name:

Job Title:

Address:

Phone:

Email:

Your Partner (by this we mean the person who lives with you for example husband, wife, civil partner, boyfriend, girlfriend)...

Title:

First name:

Surname:

DOB:

Address:

Home Phone Number:

Mobile:

Email:

Your partner’s relationship to the child you are applying for:

MotherFatherStep-parentLegal Guardian

By filling in this section you are confirming that you have informed and have permission from household members to pass their information to PhysCap Childrens Charity in respect of this application:
YesNo

OT or Physio...

Details of OT or Physio (please note we need a covering letter or report supporting this request in order proceed with any application) following an assessment:

Title:

First name:

Surname:

DOB:

Address:

Home Phone Number:

Mobile:

Email:

Household Income...

Household Income:
Under 10,00010,001-15,00015,001-25,00025,001-35,00035,001-55,000Over 55,000

Total Savings:
Under 1,0001001-10,00010,001-20,00020,001-30,000Over 30,000

Monthly rent/mortgage amount:

Do you/your partner or any parent of the child you are applying for (even if living in a different household) receive any of the following.
Where applicable enter who receives the benefit and the amount
:

Universal Credit:
Child tax credits:
Income based job seekers allowance:
Employment support allowance:
Housing benefit:
Council Tax benefit:
Working tax credits:
Income support:
Incapacity benefit:
Pension credit:
Carers Allowance:

Child's details...

First Name:

Surname:

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Gender:

School/ Nursery or child care provision attending (full time/Part time):

Details of child’s condition or diagnosis if known :

Details of professionals currently offering support, names and contact numbers(Physiotherapists, Occupational Therapists, Social Worker)if different to information already provided:

Does your child currently have an EHCP/EHP (Education and Health Care Plan, Early Help Plan) :

yesno

Details of child’s condition or diagnosis if known :

Does your child live with you on a full time or permanent basis
Please give details
:

Is your child the subject of a local authority care order (adopted, Looked After or subject to a Special Guardianship Order). Please give details:

Select the Rate of DLA or PIP your child has been awarded:
High rate careMiddle rate careLow rate careHigh rate mobilityMiddle rate mobilityLow rate mobilityPIP CarePIP EnhancedPIP Standard

If your child does not get DLA or PIP have you:
Not appliedWaiting for a decisionBeen refused

Has your child been awarded money via a legal claim for child – please provide details:
:

Have you applied to other charities and what was the outcome:

Is there any statutory financial assistance for this item?
Please give details
:

Equipment / Therapy Request

Please provide information about how you would like PhysCap to support your child
Please include details of the impact this will have on your child’s quality of life and how it will support them with their needs. Please include costings (and also upload the quotes you have received). If relating to therapy please give details of what your child/person you are applying for already has access to.
:

Brief description:

How will this equipment/support benefit the child?:

Cost (£):

Supplier name (we may request a written quotation):

Supplier telephone:

Additional information / comments:

If your application is successful do we have your permission to use your photos for testimonial & publicity literature (web, email, flyers, etc.)?:

YesNo

Do you give permission for PhysCap and their corporate sponsors to contact you with future events, promotions and offers?:

YesNo

How did you hear about PhysCap?:

Have you ever applied for funding to PhysCap before this application?:

YesNo

If your application is successful, please may we use your story to promote the charity, so we can help more children?

YesNo

IF YOU ARE STRUGGLING WITH THIS FORM PLEASE EMAIL CHLOE@PHYSCAP.ORG OR CALL 0845 0845 052 2911