Charity Match Form

Ergoadaptive Go Charity Match Form
FOR USEFUL TIPS ON GETTING CHARITY FUNDING PLLEASE CLICK BELOW

https://www.youtube.com/watch?v=1r2EDUD34kI
Name of Child*

First NameLast Name
DOB OF CHILD*

MonthDayYear
Date
Name of Parent*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please can you tell us how you wish to use the pushchair and what impact it might have on your family life? *
If you are have another source of funding please give details here*

This next page is designed to help us match you to a potential charity funders and so it is worth taking a few minutes to awnser all the questions. Please see video for more information on the Charity Funding process by clicking here:
Are you a sole parent or living with a partner/spouse?*

Sole ParentLiving with Spouse
How many dependent children do you have?*
Do you have a Healthcare Professional or Social Worker who would write a supporting letter?*

YesNo
If you do not have the above professionals, do you have a School SENCO who will write a letter?*

YesNo

Please list each amount in £££s as shown below, if you do not receive an element then enter £0. You MUST complete this list, so we are sure you have included everything. Nearly all charities will insist that this information is accurate and so please ensure that there are no guesses or estimates*

Rows	Amount
Wages/Salary
Self-Employment (Net Profit)
Universal Credit
Housing Benefit (please include even if paid direct to Landlord)
Child Benefit
Child Maintenance
Working Tax Credits
Child Tax Credits
Carer or Attendance Allowance
Disability Living Allowance (DLA Care)
Disability Living Allowance (DLAM Mobility)
PIP / Adult Disability Benefits
Any other benefit or income not included above (please specify)
TOTAL MONTHLY HOUSEHOLD INCOME = £ ENTER THIS TOTAL

Employment History (for charity funding eligibility)

Some charities offer funding towards equipment if you (or another member of the household) have previously worked in certain sectors for at least 12 months. To help us check if you may qualify, please provide details of your employment history.
Current/most recent employer
Job title/role
Sector/industry
Start date

MonthDayYear
Date
End date (if applicable)

MonthDayYear
Date
Length of service

Thank you for completing the first section of the form. To enable us to provide an appropriate pushchair recommendation, we kindly ask that you complete the final section. This part of the form will request the child’s measurements.

For guidance on how to take accurate measurements, please watch our short video below:
https://www.youtube.com/watch?v=1r2EDUD34kI
Clothing size (years)*
Height (cm) (standing or lying in full extension - bottom of foot to top of head)*
Weight (kg)*
Condition/s*
Priority use for push chair*

Local trips near homeLonger trips (normal terrain)Offroad tripsMixture of offroad trips and local trips

Measurements (cm) IT IS REALLY IMPORTANT TO GET THESE MEASUREMENTS AS ACCURATE AS POSSIBLE SO WE CAN ENSURE THE BEST FIT WITH GROWTH POTENTIAL. PLEASE REMEMBER THAT THE OVERALL CHILDS HEIGHT SHOULD BE WITHIN 5-7CM OF THE COMBINED A +B + C MEASUREMENTS. IF IT IS NOT WE WOULD ADVISE REMEASURING. AS THERE IS LIKELY TO BE A MEASURING ERROR*

Rows	Measurement in CM
Height (standing or lying in full extension - bottom of foot to top of head)
A (from bottom to top of head - see image above)
B (back of bottom to back of knee - see image above)
C (Back of knee to floor - see image above)
D (Hip to hip when in a seated position - see image above)
E (Shoulder Width - see image above)

Does your child have independent head and trunk control?*

Rows	Level
Trunk Control
Head Control

Photos of child (preferably in current pushchair)

Cancelof
We are trying to reach as many parents who need strollers as possible and so we would be really grateful if you could tell us how you found us - just the name of the website or organization would be very valuable thankyou *
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Ergoadaptive Go Charity Match Form

Employment History (for charity funding eligibility)