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Care Grant Application
Your application can be sent at any time.
Every application will be given careful consideration
and you should receive a response within six weeks of your application being received
. Please ensure that you complete a
ll sections of this form as fully as possible, as we are unable to consider incomplete applications.
If your application is urgent, please let us know.
Whether your application is successful or unsuccessful, you are welcome to apply for another care grant again at any time. However, i
f you have previously received a care grant or respite break from us, priority will be given to new applicants.
Who Is Making This Application?
*
Indicates required field
Title
*
First Name
*
Last Name
*
Relationship to child
*
If you are not the parent or main carer of the child that this application is for, please give your contact information.
Daytime telephone
*
Mobile
*
Email
*
About The Child
Full Name
*
First
Last
Date of birth
*
DD/MM/YYYY
Age
*
Under 1
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
Gender
*
Male
Female
Diagnosis and Treatment
Diagnosis
*
Diagnosis date
*
Relapse date (if applicable)
*
Is your child currently on active treatment?
*
Yes
No
If no, when did your child finish their treatment?
*
Where is your child receiving treatment?
*
Treatment Contacts
Consultant name
*
Consultant telephone
*
Where is the Consultant based?
*
Support Worker name
*
Support Worker telephone
*
Where is the Support Worker based?
*
Parents and Siblings
Main parent/carer:
This will be our main contact.
Title
*
First Name
*
Last Name
*
Relationship to child
*
Mother
Father
Carer/Guardian
Grandparent
Other - please define
If 'other', please define
*
Address Line 1
*
Address Line 2
*
Town
*
County
*
Postcode
*
Daytime telephone
*
Mobile
*
Email
*
Employment situation
*
Other Parent/Carer:
Title
*
First Name
*
Last Name
*
Relationship to child
*
Mother
Father
Carer/Guardian
Grandparent
Other - Please Define
If 'other', please define
*
Living with child?
*
Yes
No
Employment situation
*
Siblings:
Please give the full name, gender and date of birth of siblings, and other children living at the same address.
*
If there are no siblings, please write 'none'.
Please tell us a little about your current circumstance and how your child's diagnosis has affected your family
*
The Grant
All initial grant requests are for £250. Please explain how this grant would be used, including any deadlines, and explain how it would benefit the child
*
Other Information
Have you ever applied for support from Lennox before?
*
Yes
No
If 'yes', when?
*
Data Protection
Occasionally Lennox Children’s Cancer Fund is approached by the media to talk about its work. This will raise Lennox Children’s Cancer Fund’s profile, which could help us assist more families. Your answer will not
affect the outcome of your application.
Would your family be willing to represent the charity either in a photograph, on radio, on TV or by talking to a journalist?
*
Yes
No
In order for us to continue supporting families through our Care Grants project, it is important that we show the public how their money helps. We may choose to share your family’s story, photos and videos. Please be assured that we will never pass your contact details to a third party and we will never share surnames.
Would you be happy for us to share your story?
*
Yes
No
If you would like to send us photos or videos to go with your story, please email them to us at caregrants@lennoxccf.org.uk, or upload them here.
Upload File
*
Max file size: 20MB
Payment
If a care grant is awarded, it is likely to be paid to you via direct bank transfer or cheque. To speed up the payment process, please provide your bank account details. If you would prefer not to give your bank details online, please call us to give your account information by telephone.
Account name
*
The name shown on your bank statements
Account number
*
8 digits
Sort code
*
6 digits
Declaration
By submitting this application I confirm that the information I have given is correct and true to the best of my knowledge
*
Yes
Where did you hear about Lennox Children's Cancer Fund and our services?
*
Our telephone number is 01708 734366. Please save this in your phone so that you know it's us when we call you.
Please press the submit button once and wait for a confirmation message to appear.
This may take a few minutes.
Submit
