Grant Application Form

Grant Application Form

All questions marked with a star require answering.

This form should be completed by a recognised sponsoring officer. Please read our eligibility criteria policy before completing this form. All applications are evaluated using the information provided here, so please be as clear as possible. Please complete this form online or print, complete and return to the address below.

Applicants Details.

Full Name*

Address*

Tel No.*

Date of Birth.*

Email*

Next of Kin telephone number*

Does the applicant consent to this referral?*
YesNo

Referrer Details.

Full Name*

Job Title*

Organisation*

Address*

Telephone No.*

Email*

Further Applicant Information.
Please answer Yes or No

Does the applicant have a certificate of visual impairment?*
YesNo

Is the applicant in receipt of a means tested benefit?*
YesNo

Does the applicant have less than £10,000 in savings?*
YesNo

Has the applicant had a grant from us previously?*
YesNo

Further Referrer Information.

Can you confirm you will provide the applicant with training and ongoing support on the device supplied.*
YesNo

Can you confirm that the applicant understands that whilst the device is on permanent loan, it needs to be returned to us when no longer required*
YesNo

Does the applicant have access to communication equipment for example a mobile phone.*
YesNo

Can you confirm you have seen evidence of the CVI and means tested benefit.*
YesNo

Please select which means tested benefit you saw evidence of from the following:*
Income-based Jobseeker’s AllowanceIncome-related Employment and Support AllowanceIncome SupportPension CreditTax Credits (Child Tax Credit and Working Tax Credit)Housing BenefitCouncil Tax SupportSocial Fund (Sure Start Maternity Grant, Funeral Payment, Cold Weather Payment)Universal Credit

What We Offer.

Please select which device or service you require from the following - choose one*
—Please choose an option—Samsung Mobile PhoneSamsung Mobile phone with Synapptic softwareApple iPhone SEBlindshell Classic 2Samsung TabletSamsung Tablet with Synapptic softwareSamsung Tablet with SimSamsung Tablet with Sim and Synapptic softwareApple iPadApple iPad with SimLandline Provision

Sim Card

Please indicate if the applicant requires a Sim card
YesNo

Supporting Statement. To be completed by the referrer.

Please state in no more than 150 words why you think the applicant
would benefit from this grant.*

I have made this application in the best interests of the applicant and the personal information I have provided about the applicant is accurate to my knowledge. I have explained to the applicant that, in making this referral, I am sharing their personal data, including health information, and the applicant has agreed to this. I have explained that Individual Technology Solutions will be using the information to assess their grant application.

I confirm I have explained the application process and have the permission of the applicant to share all the information included within this grant application. (Please note that we are unable to consider grant applications where you do not have permission to share such information.)

Have you read the above statement?

please print your name to confirm *

Impact Measurement.

Individual Technology Solutions always try to provide positive, sustainable outcomes for our clients and to help us to achieve this we ask you to answer the questions below. We will then ask you to answer questions in 3 months’ time to see if we are making a difference.

Please answer the questions Yes or No

Do you feel you are being excluded due to lack of access to communication equipment?*
YesNo

Has the cost of equipment prevented you from keeping in touch with family and friends? *
YesNo

Has this lack of contact left you feeling isolated?*
YesNo

Do you have access to the internet?*
YesNo

For these questions you can choose more than one answer

To select more than one answer please hold down the ctrl button on your keyboard to allow multiple selections.

How do you communicate with family, friends and others for example your GP?*
—Please choose an option—In PersonUsing a telephoneUsing the internet

How do you read correspondence? *
—Please choose an option—UnaidedUsing a magnifierUsing TechnologyUsing sighted assistance