COURAGE TOGETHER CIN APPLICATION FORM

COURAGE TOGETHER APPLICATION FORM

BBC Children in Need Family Fund
CONTACT DETAILS OF PARENT/CARER
Name*
Address*
Address
Post Code*
EMAIL ADDRESS*
Phone Number*
WHAT TYPE OF EQUIPMENT ARE YOU APPLYING FOR? E.G COOKER. FRIDGE, CLOTHING, ETC*
WHY ARE YOU APPLYING FOR THIS?*
HAVE YOU APPLIED ELSEWHERE FOR ASSISTANCE WITH THIS ITEM? If Yes, who?*
PLEASE PROVIDE THE FULL NAME OF THE CHILD WHO REQUIRES THE ITEM*
WHAT IS YOUR RELATIONSHIP TO THE CHILD*
PLEASE PROVIDE THEIR DATE OF BIRTH*

MonthDayYear
Date
HOW MANY CHILDREN IN THE HOUSE WILL BENEFIT FROM THIS ITEM*
NAMES AND DATES OF BIRTH OF CHILDREN IN THE HOUSEHOLD THAT WILL BENEFIT*
IS THE CHILD WHO WILL BENEFIT LEGALLY RESIDENT IN THE UK?*
DO ANY OF THE CHILDREN HAVE A DISABILITY? IF SO PLEASE PROVIDE DETAILS*
PLEASE DETAIL THE FAMILY CIRCUMSTANCES AND WHY YOU ARE APPLYING*
Tell us about the emergency or unexpected occurrence that has led to this application and how it impacts the child*
By submitting this application I agree that:

I have provided information that is complete. true and accurate to the best of my knowledge and belief I consent to disclose all personal information within this application to Family Fund Business Services in accordance with the "General Data Protection Regulation agreement for Client Representatives"

Courage Together is acting on behalf of Family Fund Business Services, which is a working name of Family Fund Trading Limited. You have been provided with the Terms and Conditions and Data Protection statement for CiN EEP and you have understood they will rely on them and agree to be bound by them. By providing us with your information, including sensitive personal information, and signifying consent to us. you will be providing your explicit consent to Family Fund Business Services using any sensitive personal information contained within your application in order to understand whether you, your child and your personal or family circumstances

I confirm I will email to info@couragetogether.org the following:

1.     Recent bank statement (within 3 months)

2.     Proof of any benefits such as universal credit, family allowance, etc

3.     Form of identification such as copy of licence, passport
DATE*

MonthDayYear
Date
TIME*
Should be Empty:

COURAGE TOGETHER APPLICATION FORM

CONTACT DETAILS OF PARENT/CARER