XIII HEROES HUMAN NEEDS APPLICATION
FORM
1.
Personal Details
Surname
First
Names
Title
(Mr/Mrs/Miss/Ms/Other)
Date of Birth
Age
Address
..
Postcode ...
..
Tel. No:
Email address
2. Your Injury / Circumstances
Level
of your injury/need (e.g. T6 Paraplegic)
.
What
year did you sustain your injury?
.
Name
of hospital/care unit you attended
Do you require a carer? YES c
NO c Full time c Part time c
3.
Name and
address of your GP and/or consultant
.
.
4.
Describe the
equipment/services/support you are requesting
.
.
Cost
of the equipment/services
..
Suppliers
name and address
Please attach a copy of
your full quotation for equipment/services, including any extras required.
5.
Please
explain why you need this equipment/services/support and the expected benefits
6.
Have you
tried obtaining this equipment/services or part-funding for this
equipment/services from any other source? (e.g.
wheelchair services, social services etc.)
YES c NO c If yes, please give
details
..
..
7.
What are
your financial circumstances? (e.g. income support/pension/ full
or part-time employment)
Can you make a personal
contribution towards the equipment/services cost?
YES c NO c
If yes, how much?
..
8.
Have you
ever applied to XIII Heroes for a grant before? YES c
NO c
If yes, please provide
details and date
..
..
9.
How did you
hear about XIII Heroes?
.
.
..
Patients on a spinal/itu unit must if requested obtain the signature of support
from the consultant responsible for their treatment/rehabilitation (a junior
doctors signature is not acceptable).
Ex-patients must if
requested obtain the signature of a spinal occupational therapist or
physiotherapist who understands their personal requirements.
Where appropriate the
signature of next of kin will be accepted.
I support this
application for the equipment/services/support requested which,
in my opinion will improve this persons quality of life.
Signed
Date
.
Print
Name
Title
.
.
Work address
.
Post code
Work
Telephone
..
The information I have
given is, to the best of my knowledge, truthful and correct.
Signed
..
Date
Send this application to:
The Trustees, XIII
Heroes, 11a Martin Avenue, Salem, Oldham OL4 5HF
12. As XIII Heroes
is a registered charity, grants are made up from a charitable fund. The bigger the fund, the more people we can
help.
If you are applying for a
grant before making, or waiting for a compensation claim for your injury, then
XIII Heroes could claim the grant back and thereby assist even more
people. This will not affect the size
of your compensation claim.
I agree to inform my
solicitor to add the amount of my grant from XIII Heroes to my compensation
claim and to repay that amount back to XIII Heroes upon receipt of a successful
compensation claim.
Are you currently attempting
to make a claim for compensation following your injury? YES c
NO c
If yes, please complete the
following details
Name of your solicitor
.
Address of your solicitor
.
..Post
Code
..
Telephone Number of your
solicitor