The Eileen Lecky Fund

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 NameLast Name
Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Parents Date of Birth

MonthDayYear
Date
Other Parents Name

First NameLast Name
Other Parents Date of Birth

DayMonthYear
Date
Details of Dependent Children
Name of Child

First NameLast Name
Child's Date of Birth

DayMonthYear
Date
Child's School/Nursery
Name of Child (2)

First NameLast Name
Child (2) Date of Birth

DayMonthYear
Date
Child (2) School/Nursery
Name of Child (3)

First NameLast Name
Child (3) Date of Birth

DayMonthYear
Date
Child (3) School/Nursery
Family Circumstances Category?

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 NameLast Name
Referrer's Job / Profession

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:

If you are having issues uploading your form - please email to eileenleckyfund@gmail.com
Cancelof
Should be Empty:

The Eileen Lecky Fund

Details of Dependent Children