South Tyneside Blind Welfare Association

Grant Application Form

Please read notes here before applying or download and print the form

Essential information is marked with an asterisk (*)

Name of Beneficiary:*

Address (including Post Code)*

Telephone:*

Email:*

Date of Birth:

I am registered as blind or partially sighted with my Eye Specialist / Hospital

OR

Ophthalmologist

Name of person making the application (if different): Relationship to beneficiary:
Address (including Post Code):
Telephone No: Name of professional referee (see Note paragraph 3): Job Title: Contact Address
Telephone No:

If you are applying on behalf of someone else please initial the declaration below.
I confirm that l am authorised to sign on behalf of the beneficiary and that any grant will be used for his\her benefit.

Initials: Date:

Please tell us what the grant will be used for and how it will be of benefit:
Amount of grant requested £: What is the total cost? £: How much will you personally contribute towards the cost? £: If you are not applying to us for the full amount, please tell us other organisation / trusts you are applying to for the remaining cost?
Please provide/enclose evidence of costs (e.g. estimates)
Please tell us which (if any) DWP benefits you currently receive (we do not need to know the amounts).
Are you currently employed?

Yes

No

G.P.'s Name and Address

Initials:
Date:

Please uncheck this box before submitting

Submit

Notes for applications - please read carefully

The ‘Association’ is a trust fund. The Trustees may award small grants to ‘registered’ blind or partially sighted adults/children in need, who are residents of South Tyneside, for specialist equipment or services. Whilst funding is limited, the Trustees hope to use the grants to enhance the lives of the people they represent in South Tyneside. The Trustees meet up to four times a year in the months of January, April, July and October to consider applications.

1. Beneficiaries MUST be resident within South Tyneside.
2. Beneficiaries MUST be registered with a GP in South Tyneside.
3. Applicants should provide a copy or the number of their Certificate of Visual Impairment OR a registration card number (this can be obtained from Vision and Hearing Support Tel. 0191 478 5959). The contact details of a Health or Social Care professional must be provided who may be contacted to verify the beneficiary’s registration. The Health or Social Care professional could be a G.P., Social Worker, hospital Specialist or the Rehabilitation Officer based at Vision and Hearing Support on 0191 478 5959.
4. Upload evidence of the cost for equipment or services to be purchased with the grant and grants awarded MUST be used for the specified purpose. The panel reserve the right to ask for evidence of the purchase, delivery or installation of goods/services.
5. All applicants will receive confirmation of receipt of their application together with the date of the meeting at which the application is to be considered.
6. If successful, grants will be paid directly to the supplier or provider. In rare cases a payment can be paid to the applicant. In such cases, a copy of the receipt MUST be sent to the Secretary within 7 days of receiving the goods/services.
7. Grants will NOT be awarded to Groups/Organisations or for holidays, medical treatment, prescriptions, research or transport costs.
8. Occasionally the Trustees may ask for clarification or additional information to help them to reach a decision. All applicants will receive a letter after the relevant meeting to advise whether or not they have been successful.
9. If an application is successful, the same beneficiary cannot reapply within twelve months.
10. The Trustees may decide to fully fund OR part fund the cost and/or to defer an application to a future meeting if there are insufficient funds.
11. There is no appeal against the decision not to award a grant and Trustees will not enter into discussions about individual applications.
12. If you need help to complete the application form, contact Marian.