Grant Application

Grant Application

Grant Application

Grant Application Form

Please fill in the form below, or alternatively you can download the application form here and send your completed document to: Bheardcharity@gmail.com.

Full Name:

Address:

Date of Birth:

Nursery/school:

Full Name:

Relationship to Applicant:

Address (if different):

Telephone:

Parent 1: Employed?

Yes No

Job Title:

Parent 2: Employed?

Yes No N/A

Job Title:

Level of child’s left ear hearing loss:

Mild Moderate Severe Profound Cochlear Implant

Level of child’s right ear hearing loss:

Mild Moderate Severe Profound Cochlear Implant

Hearing technology currently used:

*(Please enclose a copy of your most recent audiogram. Applications cannot be considered without valid evidence of hearing loss.)

What is the grant for, and how will the financial support benefit you in the future?

Company providing support:

Total cost of support/equipment:

Contribution from applicant/family (if any):

Amount requested from BHeard:

Have you applied to other organisations for this request?

Amount requested:

Amount received:

Pending:

Yes No

Previous applications to BHeard (if any):

Date Applied:

Amount:

Purpose:

Checklist before submitting:

All questions completed Copy of most recent audiogram enclosed Letter of support from a Teacher of the Deaf / professional enclosed Formal quotation for tuition/therapy/BSL (if applicable)

I confirm that the information in this application is true and that any grant awarded will be used only for the purpose stated.
I understand that BHeard accepts no liability in connection with any grant awarded.

Signature (Applicant):

If under 18 – Parent/Guardian Signature:

Date:

Please note if you do not receive a response within 14 days of submitting application, please get back in touch with us via email.
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Grant Application Form

I confirm that the information in this application is true and that any grant awarded will be used only for the purpose stated. I understand that BHeard accepts no liability in connection with any grant awarded.

I confirm that the information in this application is true and that any grant awarded will be used only for the purpose stated.
I understand that BHeard accepts no liability in connection with any grant awarded.