Grants application

Essential information

First name

Surname (required)

Title (required)

Other

Address (required)

Post code (required)

Phone number (required)

Email address (required)

Date of birth (required)

Are you a UK or EU Citizen, with indefinite leave to remain or with full refugee status: (required)

Occupation At Time of Injury (required)

Current Occupation (required)

Have you had your Wheelchair services assessment? (required)

What was the result? (required)

Your injury

Level of your spinal cord injury (required)

What year did you sustain your injury? (required)

Name of hospital/Spinal Injury Centre you attended (required)

Do you require a personal assistant/carer? (required)

Equipment

Describe the equipment: (required)

Cost of the equipment: (required)

Supplier’s name and address: (required)

What wheelchair are you currently using? (required)

Please explain why you require the equipment and its benefit. The more information you provide here, the easier it will be for the Committee to make a decision: (required)

Have you tried to obtain this equipment, or funding for it, from any other source? e.g. Wheelchair Services, Access to Work if applicable, other grants etc (required)

If yes, please provide details

Have you discussed this equipment with a medical professional? (required)

If yes, please provide details

Financial information

Can you make a personal contribution towards the cost of the equipment? (required)

If yes, please provide details

Please confirm you have completed the required Means Test (required)

Have you applied to Aspire for a grant before? (required)

If yes, please provide details:

How did you hear about Aspire? (required)

You and Aspire

We’d really like to keep you informed about Aspire and how our work might be able to help you, either now or in the future. If you would like to hear from us please let us know how we can contact you:

General information about Aspire:

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Information of particular interest to people with Spinal Cord Injury:

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I am happy for Aspire to share my information with spinal injury charity Back Up and for them to contact me:

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Are you currently or are you intending to make a claim for compensation in relation to your injury? (required)

Signature of applicant

I have read the Aspire Grants guidelines. The information I have given is, to the best of my knowledge, truthful and correct.

Signature (required)

Date (required)

To submit this form please make sure you press the pink "Send" button below, otherwise we will not receive your completed form. You will get an email confirmation that we have received it.

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