SMArt Moves 2 Application Form

A. About the applicant

Name(Required)

First

Last

Date of birth(Required)

Gender(Required)

Ethnicity(Required)

Parent/Guardian (if under18)

First

Last

Email(Required)

Enter Email

Confirm Email

Address(Required)

Street Address

Address Line 2

City

County / State / Region

ZIP / Postal Code

Country

Phone(Required)

Main occupation – please tick all that apply

Student

Employed

Volunteer

Other

B. About the wh equipment / repair / adaption requiredeelchair you want to buy

Your current situation – why do you need this grant? How will it support your situation?(Required)

Tell us how this grant will make a difference to you /your child. Evidence of how yours /your child’s personal mobility, participation, independence, daily activities, and health and well-being will be enhanced through the award of this grant will greatly assist your application.(Required)

If you are wishing to purchase a new piece of equipment or would like us to fund repairs, please give us as much detail as possible including name / address of manufacturer or repair shop – see below.(Required)

Supplier’s name(Required)

Supplier’s address

How much will it cost?(Required)

C. Occupational Therapist support

Occupational Therapist name(Required)

First

Last

Occupational Therapist contact detials(Required)

Assessment complete(Required)

Yes

D. Wheelchair Services (WCS) assessment

Have you had one?(Required)

Yes

What date were you seen?(Required)

Wheelchair Services name(Required)

Their contact detials(Required)

Voucher issued?(Required)

Yes

What is the value of your voucher?(Required)

E. Other funding sources

Have you looked for or obtained other funding?

Yes

Please give details below of where you have applied to and amount of funds raised (Access to Work if you are working, any charities or other organisations)

If you have considered or already set a GoFundMe page pplease give detials.

Can/will you be making a contribution from your own funds? If so how much?

F. Application documents

SMA diagnoisis letter(Required)

Max. file size: 128 MB.

Occupational Therapist or physio assessmeent/supporting letter(Required)

Max. file size: 128 MB.

Quote from supplier for yor wheelchair(Required)

Max. file size: 128 MB.

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SMArt Moves 2 Application Form

SMArt Moves 2 Application Form

2 SMArt Moves Application Form

A. About the applicant

B. About the wh equipment / repair / adaption requiredeelchair you want to buy

C. Occupational Therapist support

D. Wheelchair Services (WCS) assessment

E. Other funding sources

F. Application documents