GUIDELINES

 

Please fill out the form completely as this will enable us to process the application without undue delays.

 

Please do not hesitate to contact us via the contact page if there are any queries you may have on this application form.

 

GrANT requests

 

Please use this form to request a Grant from the charity.

 

Name:
DOB:
Contact Address:
Day Time Phone:
Evening Phone:

Patients Diagnosis:
Patients GHA Number:

 

 

 

 

Parent/Guardian Name:
Address if different from above:
Day Time Phone:
Evening Phone:
Mobile Phone:
Email Address:

 

 

 

 

Referring Department:
Name of Staff:
Position Held:
Day Time Phone:
E-mail Address:

Item requested:
Due to what illness:
 

 

 

 

 

Name of Doctor:
Address:
Day Time Phone:
Mobile Phone:
E-mail Address:

Illness Duration:
Will the item requested enhance his/her lifestyle in view of that illness?
To what extent?
Will the GHA not provide the request?
If not, why?
Is it not feasible for the applicant's family to contribute towards the purchase of the item requested?
Who will certify that the item requested is specifically tailored for the applicant and his/her needs?
What are the terms & conditions of purchase and delivery? Please include delivery time.
Please add any other information or comments necessary for the above application:
 

 



 

 

 

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