APPLICATION PACK. The Boparan Charitable Trust, 9 Colmore Row, Birmingham B3 2BJ Tel: ,
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1 APPLICATION PACK The Boparan Charitable Trust, 9 Colmore Row, Birmingham B3 2BJ Tel: , We fully welcome all applications, however please be aware that applicants must live within the UK and be aged 18 or under. Official written confirmation by an independent professional body will be required stating the applicant s condition or circumstance. This letter must be on company letterhead, with contact details. *Within the independent assessment they must state how the child will directly benefit from the request. Please find below a list of things we DO NOT fund unless in exceptional circumstances: Donations to other charities Funeral Services Ongoing appeals, treatments & therapies Holidays/ short break programmes Help with legal costs Reimbursements of funds already paid out Repayment of loans Administration or salary costs Accommodation costs Travelling costs Lease or purchase of cars Faith healing Dolphin therapy Music therapy Alternative therapy Warrantees Room Hire Service or Autism Dogs Trampolines/ Trampettes Home Adaptations/ Renovations Family Memberships Carpets & Flooring Garden Equipment/ Sheds Fencing Toy s & Computer consoles eg: Wii/ Xbox/ Play Station/ Nintendo PC s, Laptops or tablets under any circumstances. Televisions/DVD players Portable DVD/TV players Hot tubs Private School fees Sofas/ settees Non medical body and face enhancements ABA Therapy This list is subject to change at any point and is not limited. The Boparan Charitable Trust reserves the right to decline an application and is not obliged to explain any refusals. Please Note: *We reserve the right to offer a like for like alternative product. *Occasionally we may request a re-assessment from our preferred supplier. *The Boparan Charitable Trust will not pay directly into a personal bank account. *The Boparan Charitable Trust does not select equipment or treatments and only provides funding (where approved) therefore accepts no liability for any equipment supplied by third parties. The charity is not a provider or advisor in respect of equipment or any other matter. *If granted, the maximum funding for the following Items are: 1500 for Trikes and 1000 for Sensory Items. The Trustees treat each application as sensitively as possible and reserve the right to request further information as and when needed. The Boparan Charitable Trust is a company limited by guarantee and is registered in England & Wales under company No I Registered Charity No Page 1
2 APPLICATION FORM Please read the Application Guidelines before filling out this form. Failure to fully complete this form and provide necessary documents may delay or invalidate your application. THE CHILD Name of Child: Date of Birth: Age: Details of disability/illness/circumstances: How long have they had this condition? Name of the Professional supporting this application?* Telephone No. of professional supporting this application:* (E.g: OT/Social Worker) THE FAMILY Name of Parents/Guardians: Postal Address: Postcode: UK Resident: ILR Indefinite: Leave To Remain: Do the Parents/Guardians co-habit? Yes: No: Mobile No. Telephone No. Address: Name and age other dependents: Page 2
3 WISHES & DREAMS PLEASE NOTE: The Boparan Charitable Trust will only grant requests to children aged 18 and under who are resident in the UK and disadvantaged through poverty, disability or terminal illness. Your Request: Cost of Items Requested (Please remember to attach quote if necessary): Supplier: Please tell us more about you re the child his/her personality & interest etc and how the request will benefit the child: (Please continue on a separate sheet if necessary) Page 3
4 FINANCIALS In order for us to process your application, we require a breakdown of the household s financial situation. Please fill out all the details below. Failure to do so will result in your application not being assessed. HOUSEHOLD INCOME 1st Parent/Guardian (net) Wage 2nd Parent/Guardian (net) Wage MONTHLY HOUSEHOLD EXPENDITURE Rent Mortgage Disability Living Allowance Hi Maintenance/Child Support Disability Living Allowance Medium Childcare Disability Living Allowance Low Secured Loans Carer s Allowance Gas Child Tax Credit Electricity Child Benefit Water Maintenance/Child Support Council Tax Housing Benefit TV Licence Income Support Telephone Council Tax Benefit Mobile Phone Working Tax Credit Satellite/ Cable (Sky, Virgin) Jobseeker's Allowance Employment and Support Allowance Statutory Sick Pay Broadband/Internet Appliance Rentals/ HP/Conditional Sale Vehicle costs (e.g. tax, insurance, DLA Motability) MONTHLY Maternity Allowance Statutory Maternity Pay Student Loan/ Grant Pension Savings (total to date) Family Allowance Other* Fuel Public Transport Sundries/ Food Clothing/Footwear Meals/Trips Leisure Activities/Memberships Student Course Costs/Tuition Fees Private School Fees Treatments/Therapies Other* *Please specify any additional source of income/expenditure. Failure to do so may invalidate your application. If you are a foreign National, living or working in within the UK, please provide photocopies of your passport and visa documents. Page 4
5 CLAIMS Have you successfully applied to The Boparan Charitable Trust before? Yes: No: What was granted? Have you applied to any other charity for your current request? If so, please state: Charity Name Stage of Application Have you received items/grants from any other charities in the previous 3 months? If so, please state: Charity Name Item Awarded LEGAL CLAIMS Have you received any compensation by way of legal claim in regards to your child s condition? Yes: No: If yes, please specify the amount received: When was this awarded? Are you currently pursuing a legal claim regarding your child s conditions? Yes: No: If yes, please provide further details: Where did you hear about The Boparan Charitable Trust? Page 5
6 PUBLICITY Help us, to help you! At The Boparan Charitable Trust we produce a wide range of materials to tell people about our services and to raise money for our work. From time to time we take photographic images (moving and still) of subjects, and use case studies which can include these images and personal data (such as name and/or diagnosis where appropriate and consented to) to enhance and illustrate our media applications to make them more accessible, and inspiring for our audiences. By completing this form, you give us full permission to use these images and any personal information you supply to us in our media applications, which reasonably promote or advertise The Boparan Charitable Trust aims. (This may include printed publications; adverts; audio-visual and electronic materials; media work; display materials; and any other media we may use in the future.) The images will not be used for any other purpose. The copyright of any material which is generated as a result of this photographic session shall be assigned and shall be the property of The Boparan Charitable Trust. YES, I/We are willing to help with publicity, so other families can benefit too. NO, I/We are NOT willing to help with publicity. CHECKLIST o A photograph / video, if you ticked yes to publicity, to support us in helping more o o o children. Fully completed application form Written confirmation of child s condition by a professional independent body e.g. Medical Consultant or Social Worker. **(Minimum requirement for wheelchair must be confirmation from a medical professional who were present at the assessment and will state this is the correct chair for the child) stating benefit to the child. Independent quote. AGREEMENT Please be aware The Boparan Charitable Trust may contact you at any point to clarify the information provided. DECLARATION: Although this application can be completed by a supporting member of the child, this must be signed by the parent/legal guardian to validate information given. All the details that I/we have provided within this application are correct and true to the best of my knowledge. I fully understand that failure to disclose the correct information will invalidate my application. Signed: Name (Printed): Date: THANKYOU FOR COMPLETING THIS FORM. PLEASE RETURN TO: THE BOPARAN CHARITABLE TRUST PLEASE ENSURE ACCURATE POSTAGE APPLICATIONS DEPARTMENT IS PLACED ON ENVELOPE. 9 COLMORE ROW If you would like to speak to a member BIRMINGHAM of the team regarding your application, B3 2BJ please call Page 6
APPLICATION PACK. The Boparan Charitable Trust, 9 Colmore Row, Birmingham B3 2BJ Tel: ,
APPLICATION PACK The Boparan Charitable Trust, 9 Colmore Row, Birmingham B3 2BJ Tel: 0121 214 9364, www.theboparancharitabletrust.com We fully welcome all applications, however please be aware that applicants
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