Grant Application Form – arthros.org.uk

(Please note – only one small grant application permitted per person per year.)

✓ Application Submitted Successfully!

Thank you for your application. We've sent a confirmation email to your address.

A trustee will review your application and contact you soon.

Eligibility Requirements Not Met

Unfortunately, you must meet all three criteria to apply for an Arthros grant.

If you have questions, please contact us at admin@arthros.org.uk

*Have you checked that you meet Arthros' 3 criteria to apply for a grant?

Do you live in the Reading area? * Yes No

Are you aged over 30? * Yes No

Do you live with a type of inflammatory Arthritis? * Yes No

Is this application for yourself or for someone else? If someone else, then their written consent is also needed, and this form must be completed with them and signed by them.

Please complete all sections 1-5.

Date

1. About you /the applicant: -

Full Name *

Date of Birth *

Address: *

Postcode *

Email address *

Contact number *

What type of Arthritis do you have? *

Do you have any special communication requirements?

If yes – what is the best way to contact you?

2. What aids will help you?

1	What do you need a small grant from Arthros to fund? E.g. -cutlery; personal hygiene equipment, other aids? Maximum 500 characters
2.	Why do you need item/s? E.g. -advised by NHS professional? -Item not supplied by NHS? -expenses beyond your means? - other - please explain? Maximum 500 characters
3.	What tasks are you struggling with while living with Arthritis? What do you need the item/s to help you with managing? Maximum 500 characters

What difference will the item/ aids make to your daily life?
How will it improve daily life for you? Maximum 500 characters

Any other information you can tell us about how living with Arthritis affects you? Maximum 500 characters

Please state preferred supplier, items needed, and costs (total below £200)

ITEM	CODE	COST



TOTAL

Preferred supplier (Choose one from the list below):

Ableworld: www.reading.ableworld.co.uk; and shop @ 31, Boulton Rd; RG2 0NH CareCo: www.careco.org.uk and shop @ 57, London Rd, Camberley GU170AA Essential Aids (Online only): www.essentialaids.co.uk

Arthros may need further information from you before a decision can be made. Please indicate your preference for communication? phone / email / post * (*delete as needed)

Preferred communication method * Phone Email Post

If someone else is completing this form:

Name of person completing the form - if not the applicant?

Relationship to applicant

Contact number

3. Declaration:

I declare that the information given on this form is true, and to the best of my knowledge and belief complete.

Signed by the applicant: *

PRINT NAME *

DATE *

4. Consent to Information Sharing and Data Protection.

Arthros will hold successful applications for one full financial year after they have been received. All medical information will be destroyed and no record of this will be kept on the database. All unsuccessful applications will be destroyed within a month of the meeting at which they are discussed. We will hold a record all applicant's names and addresses, grant given (amount) or declined, for funds given for goods, and the organisation who made the application on your behalf, for 5 years, so that if further applications are made in that time, we are aware of your funding history with Arthros and are able to compile statistics relating to our grant-making.

Information regarding your application will be shared for the following purposes: -

- To ensure that all those involved in the grant application process, including Trustees, Organisations applying on client's behalf and other funders are aware of funding offered and with what conditions.
- To facilitate administration of grant given

It is important that your written permission is gained so that agencies are aware you agree. All information gained will be treated in strict confidence. Please sign as below if you are happy for information to be shared as needed.

Applicant Signature *

Date *

Goods will be purchased on your behalf; your information will be shared with the nominated supplier. You have a right to remove, delete, or amend the data we hold on you at any time and can do this by contacting Arthros: admin@arthros.org.uk

I hereby give consent for Arthros to share, store and be given information by any relevant agencies involved in my grant application.

Applicant Signature *

Print name *

Date *

Please complete section 5 below and then

Get help with Arthritis related needs

ARTHROS SMALL GRANT APPLICATION FORM

✓ Application Submitted Successfully!

Eligibility Requirements Not Met

*Have you checked that you meet Arthros' 3 criteria to apply for a grant?

1. About you /the applicant: -

2. What aids will help you?

3. Declaration:

4. Consent to Information Sharing and Data Protection.

5. Arthros Equality and Diversity Monitoring (Optional & Confidential).

1. Gender

2. Disability or long-term health condition

3. Living situation

4. Ethnic group

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