The Eileen Lecky Fund
Please note - we are not currently accepting grants due to low funds within the charity - we will update this site again once in a position to support
Name of Parent Applying
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Postal / Zip Code
Parents Date of Birth
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Month
-
Day
Year
Date
Other Parents Name
First Name
Last Name
Other Parents Date of Birth
-
Day
-
Month
Year
Date
Details of Dependent Children
Name of Child
*
First Name
Last Name
Child's Date of Birth
*
-
Day
-
Month
Year
Date
Child's School/Nursery
*
Name of Child (2)
First Name
Last Name
Child (2) Date of Birth
-
Day
-
Month
Year
Date
Child (2) School/Nursery
Name of Child (3)
First Name
Last Name
Child (3) Date of Birth
-
Day
-
Month
Year
Date
Child (3) School/Nursery
Family Circumstances Category?
*
Health
Poverty
Domestic Violence
Other
Family circumstances influencing your application for assistance?
*
Please give as much detail as possible to help the Trustees in their assessment, including the benefit a grant could make
Grant requested for?
*
Please add the items you are requesting a grant to purchase: e.g Bed, Buggy, School Uniform - and the value of the item e.g £20, £60
Financial circumstances of applicant
*
Please outline the applicants current financial status
Total amount requested?
*
Bank Holders Name (e.g Mrs Jane Smith)
*
Sort Code
*
Account Number
*
Name of Referrer
*
First Name
Last Name
Referrer's Job / Profession
Teacher
Doctor
Social Worker
Religious Leader
Nurse
Midwife
Health Visitor
Other
Position in organisation
*
Capacity in which applicant is known to you
*
Referrer's Email address
*
example@example.com
Referrer's Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Please download & print our Applicant's Consent, and Privacy Notice here (Please upload all pages and initial each page):
Please upload your completed scanned Applicant's Consent, and Privacy Notice form here:
*
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If you are having issues uploading your form - please email to eileenleckyfund@gmail.com
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