Grant Application

Confidential- NOT for completion by client

THIS APPLICATION MUST BE PROVIDED BY AN APPROPRIATE REFEREE WHO HAS THE CONSENT OF ALL THOSE DETAILED ON THIS FORM TO DISCLOSE THE INFORMATION HEREIN.

The sensitive information below is intrinsic to the process of the granting as the purpose of the Charity is to aid and alleviate recovery from ill health. The completion of this application and submission is made with the full consent for the use of the information in accordance with the website privacy policy.

Lead Beneficiary   
Date of Birth
Beneficiary Address
Postcode
Partner's name    Date of Birth


Clevedon Forbes Fund
Supporting with care

4 Kenn Road
Clevedon
BS21 6EL


01275 341777

If single parent, please give details of any contact, practical or financial support with other parent
Dependants' names and ages
 
Circumstances giving rise to this application
Please provide covering letter and any supporting documents relevant to this application
Grants are given to those of ‘limited’ means. Please provide information of beneficiary's income
Please provide covering letter and any supporting documents relevant to this application
Plans for use of grant
Dates (if known)
Breakdown of costs
Grant required £
Contribution by Beneficiary £
Have other grants been applied for?
Decision made yet?
To whom cheques are to be payable (NOT beneficiary):
 
 
Referred by:
Title
Name
Position held
Organisation
Address
Postcode
Contact tel no.
Email
Description of association with lead Beneficiary and length of time known
Signature
Date

Beneficiary Consent

I (name of Lead Beneficiary)   consent to:

The information provided on this form and any covering letters attached, being given to and being held by the Clevedon Forbes Fund for the purpose of this grant application.

These records, both paper and electronic, being stored by the charity once the grant has been assessed for up to 6 years or until no longer required for the purposes of litigation, and thereafter for archiving, research or statistical purposes in the public interest or otherwise destroyed.

The Grants Officer releasing relevant information to a third party for the purpose of booking a holiday on my behalf, should a grant be awarded.

Use of the information provided in accordance with the website privacy policy.



Signature of Beneficiary:           Date:




(Note: Please print this form out, sign it, and post to us)