The Edward Starr Charitable Trust Application Form

							                The Edward Starr
                   Charitable Trust
                       Application Form


 APPLICATION FOR FUNDING FOR AN INDIVIDUAL CHILD
                Before completing the form please read our guidelines on
                      ‘What we do fund’ as outlined on the website.

   Failure to complete this form fully will result in a delay to your application, as we will
                            return it to you for more information.

Funding can be considered for specific items, meeting specific needs, with specific
outcomes, within a specific timeframe. When applying please be clear about the exact
requirement for the funding, as we will not be able to pay money into a general fund.
We are unable to provide funding for costs already incurred. This means the funding
cannot be used to reimburse money that has been spent prior to the start of the project
and prior to the grant of the funding. Funding applications concerning items of an
indefinite, ongoing nature, such as operational overheads will not be considered.

1. Applicants Details

   Name of Child _________________________             Date of birth _______________________

   Child’s address
       ___________________________________________________________
       ________________________________________________________
       ________________________________________________________
   Parent/Guardian’s names _________________________________________________________

   Parent/Guardian’s day time telephone number_____________________________________

   Name of Applicant (please specify relationship to the child eg. Parent, Teacher,
   Occupational Therapist, Physiotherapist etc
   ___________________________________________________________
   Applicant’s correspondence address
       ________________________________________________________
       ________________________________________________________
       ________________________________________________________
   Applicant’s Day time telephone no __________________           Mobile telephone no
      _________________

   Email Address _____________________________
2. Previous Applications Made

   Give details of any previous applications made to The Edward Starr Charitable Trust
   on behalf the child

Year    Amount Received        Purpose for which grant was requested
____ ______________ ________________________________________
____ ______________ ________________________________________
____ ______________ ________________________________________
3. Family information

    Please give information on the child and family background including
    parent/guardian’s occupations, other children in the family etc.
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   Details of any disability
   Please give details of the nature of disability (if appropriate) and how this affects the
   child
_____________________________________________________________
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_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
   We require a detailed breakdown of the family’s financial situation
   i.e incomings, outgoings, information on mortgage or rent payments, other bills etc.
   Continue on a separate sheet if necessary:

Income                              £           Expenditure                          £
Parent’s take home wages                        Rent/Mortgage
Child Benefits                                  Council Tax
Disability Living Allowance                     Water/Gas, Electricity
Other Benefits                                  Insurances
Any other income                                Car expenses (Petrol, Tax and
                                                Insurance)
                                                Child care
                                                Household expenses i.e. food
                                                Telephone and television



Total monthly income                            Total monthly expenditure
Savings                                         Debts/Arrears
Comments:
4. Project Details & Amount of Grant

   Please give FULL details of your project/proposal. Please give us as much information
   as you can as this will help us to consider your application


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   Grant requested from Edward Starr Charitable Trust       £ __________________________
5. Costs
   Please give a detailed description and cost of requirements, and explain how each
   will benefit the child. It is necessary in the case of equipment to provide a written
   quote provided and recommended by a professional, appropriately qualified person
   – please include quotes with your application

       Please note the quotation should be inclusive of VAT unless the item is designed
       specifically for the use of disabled children.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

   Do we have your permission to contact the person providing your quote?         YES/NO

6. Other Funding

   Have you approached anyone else, or completed any other application forms for
   funding for this project?                                               YES/NO

   How much has been raised so far towards this project, and from where?

       Family                 £__________

       Local Authority        £__________

       Local Fundraising      £__________

       Other Sources          £__________     please give details ________________________



7. Testimonials

   If we are able to assist, would you agree to the inclusion of your project, a personal
   testimonial, and any related photos on our website and for publicity purposes? It is
   very important that we are able to use testimonials on our website to encourage
   further donations to enable us to continue funding projects like yours.       YES/NO

If no, please give reasons below (i.e legal reasons etc)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
   May we approach you for further information if we need it?                     YES/NO
9.Declaration

I confirm that the information I have provided in this application is true to the best of my
knowledge. It is important that any person or organisation proposing to provide
assurance to support an application be aware that the information provided will be
assessed in detail by the Trust.

Signature of Applicant __________________________

Print Name _______________________________

Date ______________________


If you do not agree to receive communications from The Edward Starr Charitable Trust

please tick the box   □
 CHECK LIST
 Please remember to enclose the following:


 □ Fully completed and signed Application Form
 □ Recommendation for Equipment
         To be provided for a professional or appropriately qualified
         person.


 □ Supporting letters/documentation
         From any related third party, doctor, Hospital, School, Charity
         etc). Letters written by parents or guardians will not be
         considered.




All information provided in relation to the application will be treated in confidence and
the handling of such information will be limited to personnel directly involved in
administering and evaluating the circumstance.

Please return to: The Edward Starr Charitable Trust, 13 Blatchington Road, Hove, East
Sussex, BN3 3YP