BUPCC FQ 2022

Welcome

to the Bristol Children's Charity
FUNDING REQUEST FORM

PLEASE READ THIS IMPORTANT INFORMATION BEFORE YOU PROCEED TO THE FUNDING REQUEST FORM
In an effort to improve our appeals procedure, we have amended our application form.

Please ensure you answer all the questions fully and as concisely as possible. Failure to submit the information requested will delay your application and it may even be rejected altogether.

All applications for funding must be completed by an official, for example; Doctor, Teacher, Social Worker, Health Care Professional (not carer), Police Officer, Support Worker.

Please tick below to confirm you have read and understood these terms:

ABOUT THE CHILD AND FAMILY
Full Name of Parent/Carer*

First NameLast Name
Email of Parent/Carer*
example@example.com
Parent or Carer's Phone Number*
Please enter a valid phone number.
Address *

Flat or House Number

Street Address

CityCounty

Postcode
Spouse or Partners Name*
Does Your Spouse/Partner live at the same address*

YESNO
Do you live in a flat*

YESNO
How many flights/storeys?*
Is there a lift?*

YESNO
Is parking easily accessible where the item(s) are to be delivered?*
Information about the child / children at the above property (please list all the children living at the property)*

INCOME - Please list ALL household income. Please note the applicant may be asked to show proof of all income and mortgage/rent payments along with more in-depth questions regarding benefits.*

	YES/NO	AMOUNT £	PAYMENT FREQUENCY
WAGE
UNIVERSAL CREDIT
DLA
HOUSING BENEFIT
INCOME SUPPORT
PIP
CHILD BENEFIT
PLEASE LIST ANY OTHER FORM OF IINCOME HERE

MONTHLY OUTGOINGS.*

	YES/NO	AMOUNT £
RENT
MORTGAGE

Who is completing this form*
Please state who you are in relation to the child

ABOUT THE SUPPORTING APPLICANT
Name of the supporting applicant (i.e. Doctor, Social Worker, Teacher etc)*

First NameLast Name
Business address of the supporting applicant*

Street Address

Street Address

CityState / Province

Post Code
Email of the supporting applicant*
example@example.com
Landline number of the supporting applicant
Mobile number of the supporting applicant*
Has a home visit/inspection been carried out*

YESNO
Does the applicant have any form of Communication difficulties? If yes please specify.*
PLEASE DO NOT REQUEST ITEMS FOR ANY PERSON OF 18 YRS OR ABOVE – THIS WILL NOT BE CONSIDERED.

SCHOOL UNIFORM REQUESTS
Are you applying for School Uniform(s)*

YESNO

Uniform can be chosen from George at ASDA, please list all the items required below, alternatively make a wish list from George in the box provided below

	Item Required	Size	Colour	Quantity
UNIFORM 1
UNIFORM 2
UNIFORM 3

Uniform Wish List

DO YOU NEED SOMETHING THAT IS NOT ON THIS FORM?
Please list any items not listed on this form that are required by the child/family. giving a full account of size and quantity.

PLEASE TELL US WHY YOU NEED OUR HELP
Please give a a detailed explanation of why this child/family need our help and how the child/children will benefit*
In order for us to consider this application fully, please ensure you provide as much detail as possible, i.e the child’s/children’s health/well being/medical condition etc. The financial position of the parent/carer.
Has this family made an application to this Charity in the past 12 months?*

YESNO
Have you applied to any other charities or organisations for help with any of the items listed above?*

YESNO
If yes, please give details of any organisation approached
Should be Empty:

	Yes	No
Divan Base
Cardiff Mattress
Silver Bunk Beds
Cot
Cot Bed

	Yes	No
Washing Machine Electra W1245CT0W
Fridge/Freezer MC50165ES
Electric Cooker 50cm Beko KD531AW
Electric Cooker 60cm Electra TCR60W
Gas Cooker Electra TG60W
Condensor Dryer Electra TD8101W 8kg

	Washing Machine	Cooker	Fridge	Fridge Freezer
Yes
No
N/A

Welcome

FUNDING REQUEST FORM

PLEASE READ THIS IMPORTANT INFORMATION BEFORE YOU PROCEED TO THE FUNDING REQUEST FORM

ABOUT THE CHILD AND FAMILY

ABOUT THE SUPPORTING APPLICANT

BED REQUESTS

SCHOOL UNIFORM REQUESTS

DOMESTIC APPLIANCE REQUESTS

DO YOU NEED SOMETHING THAT IS NOT ON THIS FORM?

PLEASE TELL US WHY YOU NEED OUR HELP