Website Questionnaire Form

1 Child's Full Name

First NameLast Name

Date Of Birth

Date

Gender?

2 Address

Street Address

Street Address Line 2

CityCounty

Post code

3 Details of Childs Health Condition

4 Details Of Adult Submitting Application

First NameLast Name

Street Address

Street Address Line 2

CityCounty

Post Code

Phone Number

Area CodePhone Number

Email

example@example.com

Relationship To Child

5 Organisational Applications

Organisation’s Name & Charity Number

Objectives of Organisation

Details of Holiday or Respite Break or Project

Number of Children aged 2-17 with a continuing health condition or learning disability who will benefit?

6 Previous Charitable or Organisation Applications

Have you applied to the Adamson Trust before?If yes, did you receive an award?Have you applied to other charities or organisations?

Where did you hear about the Adamson Trust?

7 Details of Holiday or Respite Break i.e., where, when and costs including travel expenses. Also, how the child will benefit. Booking receipts if available.

File Upload - Organisation’s audited accounts/Medical documents/Letters/ Social Work/ DWP reports etc.

8 Declaration
Please compleate the form below confirming that you have have the legal right
to request the funding on behalf of the child.

The Adamson Trust is not liable for the choice of holiday/respite break sought on behalf of the child as the Trust only provides a modest financial contribution to be used in connection with the chosen events. Please note that by signing and submitting this form to the Adamson Trust you are agreeing to the terms and conditions set out below.

You are responsible to have taken medical advice where appropriate, as to the suitability of the holiday/respite break and the capacity (whether physical, mental or otherwise) of the child to take part in it, all activities involved and all matters associated with (such as, but not exclusively, travelling and accommodation involved).
You will remain fully responsible for the child at all times. It will remain your responsibility to assess the suitability of any accommodation, activity or
otherwise proposed in respect of the child.
you are responsible for reading the form and fully understand the conditions of any grant awarded. You are responsible to certify that the information given on this form is to the best of your knowledge correct.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Organisational ApplicationsOrganisation’s Name and Charity Number

The Adamson Trust Application Form