Grant Application Form

Please note all sections must be completed for your application to be considered.

The Supporter section must be completed by your supporter. If you require us to send a copy directly to your supporter, please let us know.

This form along with scanned copies of your supporting documents can be emailed to maria.smedstad@guidedogs.org.uk Printed copies can be posted to the address stated in the checklist.

Applicant detailsApplicant Name:

D.O.B:

Nationality:

Gender:

Ethnicity of child:

Resident in the UK – Number of Years:

Certification categorySeverely sight impaired (blind):☐Date certified:

Sight impaired (partially sighted):☐ Date certified:

Please enclose a copy of Certificate of Vision Impairment (CVI), or letter from Ophthalmologist if your child is not certified.

Applicant’s Visual Impairment(s):

Other Health issues:

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Visual Acuity Level and font size (where appropriate):

Is your child receiving support with habilitation/mobility:Yes ☐ No ☐

Supplier:

Have you been in contact with Guide Dogs before: Yes ☐ No ☐

Parent or Guardian Information Name:

Address:

Postcode:

Is the applicant living at this address? Yes ☐ No ☐

Tel no:

Mobile no:

Email:

Are you receiving Annual Carers Allowance: Yes ☐ No ☐

Are you receiving Annual DLA (disability living allowance): Yes ☐ No ☐

Are you receiving any other allowance(s): Yes ☐ No ☐

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Item(s) applied forWhat item(s) are you applying for? Please include a separate quotation:

We may be able to help you source a quote. Please get in contact with details of the item(s) you wish to apply for, if so.

Why do you require this equipment/software (suggested word count 50-300):

What do you anticipate the outcome this will have for the applicant:

Does the applicant have access to this equipment at school? If not what equipment and software are they using:

What experience does the applicant have using this equipment:

Please list home/family equipment the applicant has access to at home, including laptops and iPads:

Pre-School/School/ College attended by applicant Establishment name:

Date started:

Date of/due to leave:

Does the applicant have a Statement/Action/ActionPlus/EHC Plan? Yes ☐ No ☐ (Not applicable in Scotland)

Other sources of financial supportHave you applied to any other organisations for help with this request?Yes ☐ No ☐

If yes, please give details including secured funds:

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Supporter section

Supporter detailsSection to be completed by the applicant’s VI Professional.

A separate supporting letter must be enclosed.

The supporting letter should be addressed to Guide Dogs’ Grant Service. It must be signed, submitted on headed paper and should explain how the equipment applied for will be of benefit to the applicant.

Name:

Job Title:

Name & Address of organisation:

(t):

(m):

Email:

In what capacity do you know the applicant:

Supporter signaturePlease enter your full name below. By entering your name, you are confirming that the named child has a recognised visual impairment and will submit a separate supporting letter as stated above.

Name:

Date:

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ContributionBy completing this application form you are agreeing to make a contribution of 10% of the total cost of the products. This amount will be payable if your application is successful.

We will request payment before any items are purchased. For further information please see criteria.

You may be contact by a member of the Access Technology team to evaluate your application before it is presented to the board. Please state the best time and day during the week to contact you:

The decision to support will be made by a board of professionals from Guide Dogs for the Blind and every decision is final.

Declaration I confirm that the information given is complete and correct. The personal information collected in this grant form, and in the course of

providing this services, (including that which relates to your child’s health and other needs) may be used by Guide Dogs to provide and administer their services and monitor their quality.

I agree that the information supplied on this form, including details about my child’s sight condition, may be used in order to deal with this application and may lead to a further service referral or information of other support services within Guide Dogs.

I agree that Guide Dogs may discuss the information on this form with other organisations, education provider (school), Sensory Support Team, and Local Authority in order to gain further information related to this application and to assist with possible funding.

I understand this form is a request for a grant to be considered by the Guide Dogs grant board and that the grant board’s decision is final.

I understand that if funding is agreed, Guide Dogs are not required to provide payment towards the upkeep of equipment or software, including replacement, insurance, antivirus/security software, maintenance and warranties.

I consent to any photographs or thank you letters I send to Guide Dogs may be used for publicity purposes both online and in printed materials.

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I understand any equipment and software provided by Guide Dogs is for home use only. The provision of equipment and software within an educational environment is the responsibility of the education provider.

I agree to a 10% contribution towards the total cost of items should the application be successful.

I have read and understand the Guide Dogs Grant Criteria. I understand that all sections of this form must be completed for the application to

be considered and that incomplete forms may be returned to the applicant for further information.

Declaration signaturePlease enter your full name below. By entering your name, you are confirming that you have read and agree to the above declaration.

Name:

Date:

Relationship to Applicant:

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ChecklistPlease note all sections must be completed for your application to be considered.

Please tick to confirm that you have completed/included the following, without which your application will not be considered.

Form Completed and Signed ☐ Form signed and separate supporting letter from VI professional enclosed ☐ Quotation of equipment and software ☐ Copy of CVI or letter from Ophthalmologist ☐

Emailed documents can be sent to: maria.smedstad@guidedogs.org.uk

We are able to consider scanned and emailed copies of CVIs, ophthalmologist letters, quotations, supporter letters and Statements. Please note that these must be deemed as having been submitted at an acceptable standard, before we are able to process your application.

Printed copies can be posted to

Guide DogsChildren and Young People Services Grant Service48-62 Woodville RoadHarborneBirminghamB17 9AT

It is recommended when sending printed copies, that you obtain proof of posting or record delivery.

End of document

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