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Are applying for grant application or loan application?*

Grant

Loan

Do you have a professional supporting letter?*

Yes

Do you have a quote?*

Yes

Child's Details

First Name*

Date of Birth*

Surname*

Gender*

Female

Male

Non binary

Prefer not to say

Please tell us the child/young person’s diagnosis and prognosis (please attach separate sheet if required):*

Please tell us how you think we can help your child/young person at this time and how any equipment provided would make a difference:*

What is the equipment you would like Newlife to consider funding?*

Please tell us how your child/young person is affected by not having this equipment:*

Would you like to donate towards the cost of the equipment? *

Yes

If yes how much?

Is the child/young person currently in hospital? *

Yes

Is the child/young person a resident of the UK? *

Yes

How would you describe the child/young person’s family situation? (Tick any that apply) *

Living mainly with one parent

Living with both parents (include step-parents)

Residing in School

Looked After Child (Local Authority has parental responsibility)

Court issued Special Guardianship Order

Residing in Care Home

Living with care given, at different locations, by both parents

Fostered

Court issued Child Arrangement Order

Adopted

Other (please specify)

Other

Is your child/young person awaiting hospital admission for surgery or tests? *

Yes

Is the equipment needed for hospital discharge?*

Yes

Please confirm the date and how long they are likely to be in hospital for.

Which professionals have provided care to the child/young person in the past two years? Please give their role and where possible, details of their employer and the care setting within which they deliver care; e.g. Physiotherapist, funded by NHS, delivering treatment in school.

If old enough to attend school, does the child/young person go to a: *

Mainstream school

Mainstream school and has support/extra/special lessons

Mainstream school and uses a special unit

Attends a special school

Is educated in a different way, please give details:

Details

Is the child/young person a resident of the UK?*

Yes

Does the child/young person have an Education, Health, and Care Plan (EHCP) or Statement? *

Yes

In Process

when is it due its annual review?

Is there any other information you would like to share to help us understand your child/young person’s needs?*

Child Demographic Information

Please tick the box that you feel is most appropriate:

Background*

White - English/Scottish/Welsh/NI

White - Irish

White - Gypsy or Irish traveller

Any other white background

Asian/Asian UK - Indian

Asian/Asian UK - Pakistani

Asian/Asian UK - Bangladeshi

Asian/Asian UK - Chinese

Any other Asian background

Mixed ethnic background

Black/Black UK - African

Black/Black UK - Caribbean

Any other Black/African/ Caribbean background

Arab

Any other ethnic group

Prefer not to say

Parent/Primary Carer details

Mrs

First name*

Surname*

Address*

Postcode*

Tel. No*

Mobile*

What is your preferred language?*

Email address*

Have you used our services before? *

Yes

How did you hear about our services?*

What is your relationship to the child/young person?*

Do you have any health conditions/disabilities or mental health difficulties? Please provide as much detail as possible as Newlife’s Child and Family Support Team consider the difference that equipment provision makes, to the whole family. *

Are there any other children or siblings of the child/young person, living in the same home? *

Yes

Please give their gender, age and state if they have any significant health conditions/disabilities:*

Do you receive any of the following benefits (tick any that apply)? *

Universal Credit (This may include, income support, housing benefit, ESA, JSA, Working Tax Credit, Child Tax Credit)

Personal Independence Payment/ Disability Living Allowance

Council Tax Relief

Pension Credit

Blue Badge

Lease of vehicle through Motability

Not applicable

Professional's Confirmation of Loan or Grant *

Grant Application

Loan Application

Professional Details

First name*

Surname*

Job Title*

Address*

Postcode*

Work Tel. No.*

Mobile:*

Email*

In order to progress your application to the next stage we will require the professional support to be submitted with your application. The professional involved in your child/young person’s care will need to complete the following information in a letter on their organisation letterhead confirming:

Childs name
Date Of Birth
Confirmed/Suspected diagnosis or condition
What is the cause of the condition/disability? Prematurity? Genetic? Infection? Trauma? Cancer? Unknown? Other (Please specify in professional letter)
Is child/young person’s condition considered to be a: Significant disability? Life threatening condition? Life limiting condition? Terminal illness?
- Newlife defines a significant disability as being a physical and/or cognitive impairment which affects activities of daily living. A life-threatening condition should be defined as a condition whereby the next period of ill health would make it likely that life- sustaining intervention would be needed. Newlife defines a life-limiting condition as a condition that results in a shortened life expectancy, as opposed to having limited life experiences that could affect quality of life. A terminal illness is generally defined as not being expected to live longer than six months and/or a person who has an advanced care plan to meet end of life care needs.
Why the equipment is being requested and is this considered to be urgent?
Full confirmation of specification.
Has a funding request been made to relevant statutory services/other charities, what was the outcome?

Terms and Conditions

All the information given in this application process is up to date to the best of your knowledge.
Newlife is a Charity and while we will try to help as many families as possible there may be occasions that we are unable to help.
We will share personal information from your application with professionals working within Health/Social Care and trusted equipment providers, this helps us to facilitate the grant/loan. For more information see our privacy notice on our website.
Please remember that the equipment provided should be used for the intended child/young person and should not be used by anyone else.
The Equipment may be provided to you as a charitable act. We will therefore only be responsible for any loss or damage that you suffer in connection with this agreement, to the extent that we are able to claim for such loss or damage under our insurance.
Following delivery of equipment, we will contact you to gather feedback on the service you received and the difference made by the use of the equipment.

If an equipment grant is offered, you are agreeing that:

Newlife may offer new or fully refurbished quality equipment.
Newlife will place the order directly with the equipment supplier. Please note that any orders placed with equipment suppliers prior to Newlife being able to fund will invalidate this application.
Once equipment is delivered, you as the parent/carer will take on the ownership of this equipment for use of the named child/young person. If the equipment appears to have been delivered in any state of disrepair please refuse delivery and follow up with Newlife while it remains our order. Signing for the delivery means that it will be your responsibility to raise issues/concerns with the equipment supplier.
The maintenance, repair and insurance of the equipment remain under your own control.

If an emergency equipment loan is offered, you are agreeing that:

You won’t use the Equipment until you have received the initial training which will be provided by one of our equipment suppliers. Please follow all instructions and recommendations provided to you.
If you no longer need the Equipment, please contact us and we will arrange for the Equipment to be collected from your home or nominated address.
Please let us know if the child/young person’s needs change during the loan we may be able to support you further.
We do reserve the right to recall the equipment, but we would give notice if this was the case. If the Equipment is lost, stolen or damaged whilst it is in your possession, please get in contact with us straight away and we will try to support you.
Newlife will insure against all loss, theft or damage to the Equipment; public liability; and product liability whilst you are in possession of the Equipment. Our insurance covers the Equipment whilst it is in the United Kingdom and for up to 90 days in other countries of the European Union. For use outside of these conditions, you will need to contact us to get approval. Under these circumstances, you may need to personally insure the item. You need to understand that you may also be held responsible, if you seriously misuse the Equipment or use it whilst it is knowingly faulty.

Family Declaration

Do you agree to Newlife providing the child/young person’s basic information to help demonstrate how specialist equipment can change young lives, help promote our services to other families, encourage fundraising and donations as well as help raise general awareness of the charity? This will be information such as name, age, county, description of their condition and the difference the equipment will make. *

Yes

It’s important, that we can share some basic information. This is common with most charities who are highly dependent on the public to help them meet the needs of children and their families.

Do you agree to provide a photo of the child/young person that could be used to highlight how equipment helps which would be shared with donors, supporters and families? *

Yes

Would you be interested in speaking to our volunteering team about wider opportunities to support the charity? *

Yes

Do you consent to allow Newlife to share your personal data with third parties to help Newlife analyse what we do? *

Yes

In these cases Newlife will remain the Data Controller but will simply share your data for the purpose of data analysis only. In all cases we will use a non-disclosure agreement to ensure that the third party does not misuse any data provided.

Who has completed this form?*

Parent/Carer

Professional

Professional Supporting Letter with a quote specifying equipment needed*

Any other documentation

For all the questions above where we ask you if you are happy to be contacted by a Newlife team, other than the Child and Family Support Team, please specify your preferred method of contact (please tick all that apply):

By Post

By email

By phone

As a charity, it is necessary to raise funds to be able to continue our service to children and families. Are you happy to receive updates and news including other ways to get involved from our fundraising team? *

Yes

By ticking the statements below and signing this form, I agree to the terms and conditions (as stated above), confirm that the provision of equipment is necessary and essential to support the named child within this application, and also confirm that this child meets the following criteria: *

A UK resident

Under 19 years of age

Has a disability which affects their daily life and means that equipment is needed, a life threatening/life limiting condition or has been diagnosed as terminally ill.

Agree to the terms and conditions

Have you attached*

Have you attached your professional supporting letter

if your applying for a grant - have you attached a quote

Have you attached a photo of chid if that is your preference

This field should be left blank

Equipment application form

Child's Details

Child Demographic Information

Parent/Primary Carer details

Professional Details

Terms and Conditions

Family Declaration

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