miriam-trust by blindlove200

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									               Are you 18-35 and living with cancer?
               If so the Miriam Charitable Trust can
               help.
 The Miriam Charitable trust was set up in honour of Miriam Eaton by her family and friends. Miriam
 died of lung cancer in August 2001, aged 26.

 The Trust provides financial assistance for a wide variety of practical needs, including:

    •   Travel costs      Childcare           •
    •   Complementary Therapies
                          Respite Care        •
    •   Social Activities/Breaks
                          Domestic Help       •
    •   Non-NHS wigs                          •
                          Variety of other needs on
                          request
 _________________________________________________

            A copy must be held in the Patients records and the Patient must sign this form

 From: (Healthcare professional or social work professional)

 Name:………………………………………………………
 Title:……………………………………………………….
 Date:……………………………………………………….

 Please send a cheque for the following amount:
 £…………………………….                  (figures)
 ………………………………………………………………………………………………… (words)
 Made payable to:………………………………………………………………………………
 Address cheques to be sent:………………………………………………………………………………
 ……………………………………………………………………………………………………………………
 ……………………………………………………………………………………………………
                                                                      Patient
 Purpose
 ………………………………………………………………………………………..                                  I accept that my name and address
 ………………………………………………………………………………………..                                  may be supplied to the above charity.
                                                                      I agree that the money received will
                                                                      only be used for the purpose outlined
 Please tick to confirm that                                          above.
    • The Patient has cancer
    • The Patient is aged between 18 – 35                             Signed:………………………

                                                                      Print:………………………….
Please send the application form to: The Nurse Director, Sussex
Cancer Network, 36-38 Friars Walk, Lewes, Sussex, BN7 2PB


                   The Miriam charitable Trust, UK Registered Charity no. 1092706

								
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