Tel: 01206 323420 | Email:
info@colchestercatalyst.co.uk
About Us
How We Help
Applying for Grants
Dates of our Next Meeting
News
Search
Online SIN Form Application
You are here:
Home
/
Online SIN Form Application
Online SIN Application Form
Your message was sent successfully. Thanks.
Name
Address
Postcode
Telephone
Email
*
Date of Birth
Please tell us about your disability and how this affects you?
*
For what purpose do you require a Grant? - How will the provision improve your health care?
*
Name of Medical Professional supporting your application? Please arrange for a letter to be sent to us.
We will need a separate letter from them confirming this.
Telephone
Email
What is his/her profession
*
Select Option
Doctor
Nurse
Occupational Therapist
Physiotherapist
Social Worker
Other
Has an assessment of your need ever been made by Social or Health Services?
*
Yes
No
If YES, when was the assessment carried out?
And what was the result?
If NO, why not?
Please describe the equipment required. Please send written quotations as soon as possible. If you are applying for a scooter or electric wheelchair, we will need a completed assessment form to demonstrate safe use, storage and maintenance before we can consider your application.
Finances of Person needing help - Replies to this section are mandatory and are essential to us in considering this application. Although any grant is not means tested, the purpose of this fund is to assist people with limited means to meet the special individual health needs above and beyond statutory provision. If the person applying is under 18, the entire family income should be recorded. If your income is in excess of £30,000 per annum please explain why you are not able to self-fund? Cheques cannot be made to individuals
Income/Salary:
*
DLA Care / PIP Daily Living
*
DLA Mobility / PIP Mobility (How is this being used? ie car
*
Income Support
*
Pension
*
Child Benefit
*
Savings
*
Other Benefits e.g. Universal Credits, Tax Credits
*
Total Annual Income
*
What is the total cost of the equipment?
Amount requested from Catalyst?
What contribution could you make? Please note we never fully fund any equipment, a reasonable contribution will be expected.
Funding from other sources?
If you are completing this form for the applicant, please give your name, address, relationship and telephone number
Your Name
Address
Postcode
Email
*
Relationship
Telephone
DECLARATION - I declare that the information given in this form is correct & complete and I am aware that this application will be discussed with relevant health professionals and/or other charities in order to help Colchester Catalyst Charity make a decision on my application.
*
Submit
General
Special Individual Needs
Respite Care
Counselling
Criteria for Grant Making
Scroll to top