Victoria Hospital Incorporated

Grant application for medical or medically related expenses.

By completing and submitting this form, you confirm that this information is accurate and agree that Victoria Hospital Incorporated can use the details that provided to process your grant application, including any sensitive information such as details about your health.

You may complete the application on behalf of someone else only if they have given you explicit permission to do so.

You can find out more about how we will use your information in our privacy statement which can be found online.

Email [email protected]

Applicant

First Name Last Name Age Address Telephone Email Occupation

Spouse or Partner

First Name Last Name Age Occupation

Dependants

First Name Last Name Age First Name Last Name Age First Name Last Name Age

Application Details

What amount are you applying for? If it is for a grant for equipment, then please give an estimate. Note that if it includes doctor’s bills, we are not usually able to consider any over two years old.

Please give brief details of why you are applying for this grant including any relevant medical needs.

Please include a summary of any accident, illness or other change of circumstances that may have significantly affected your household financial situation.

Have you applied to Social Security for help with your medical expenses? If you have been refused, what was the reason given?

Have you asked for assistance with this claim elsewhere? Please give details

Financial Details

Household Income (self and partner) Weekly Monthly

Earnings Pension(s) Child maintenance received Income Support Other benefits (specify below)

Household Expenditure Weekly Monthly Annually

Rent or mortgage including TRP and parish rates Maintenance payments Food and housekeeping Services (Power/telephone/transport etc.) Sundries (Clothes, household goods, etc.), on average Healthcare costs (GP visits, prescriptions etc) Loan repayments Do you have any outstanding debts? If so, please give brief details.

It may help us help to process this application more quickly if we can contact the following:

Please tick the box if you agree

Social Security Only tick this box if you do NOT want us to contact social security.

Medical or other professional(s) please provide contact details if ticked Only tick this box if you do NOT want us to contact medical or other professional(s).

If completed on behalf of the claimant

I certify that the claimant has agreed to me submitting this claim for them and that the information provided is an accurate and complete record of that provided to me by them or is otherwise within my knowledge.

First Name Last Name Telephone Email Profession and organisation Date

Data Protection

The information provided will be retained electronically, unless you object. Only tick this box if you do NOT want this information stored electronically.

Please confirm that the data entered is accurate

I certify that the information provided is accurate and complete.

Assistance Request Form