• Rob Smith"Regain has been very supportive to me and my family and many major moments and memories of my life have happened with Regain"
  • The Jordan Bike Ride for RegainJoin the next amazing Regain overseas cycling challenge in Jordan
  • Sports Award LuncheonCome along to the annual Regain Sports Award Luncheon
  • Leave a LegacyLeave a Legacy to Regain
  • Dr Owen LoweryDr Owen Lowery is a Published Writer and Poet, with a PHD for Creative Writing
  • Alex Rickham (Rio Olympic Medalist)"Regain has been an inspiration to me. Regain supported me in my bid to get into the GB Wheelchair Racing Team at the Paralympics. Without Regain’s help I would never have achieved so much"
  • Dragon Boat Racing 2017

Apply for a Grant

Please complete the application form below to apply for a grant from Regain. Accompanying letters should be e-mailed to enquiries@regainsportscharity.com or posted to Regain C/O Action for Charity, Newcourt House, New Street, Lymington, Hampshire, SO41 9BQ.
   
PERSONAL DETAILS  
Surname
Christian Name(s)
Age
Address
Contact Number
E Mail Address
INJURY DETAILS  
Occupation at time of Injury
Your current Occupation
Date of Injury
Level of Injury
Complete or Incomplete
Describe how the injury occurred
Describe ability - and how your injury impairs you
EQUIPMENT / GRANT REQUEST  
Have you had a Regain grant before and if so how much ?
How did you hear about Regain ?
Describe the Equipment / Grant Request
Cost of the Equipment / Grant Request
Please describe how you will benefit from the Equipment / Grant request
Have you tried obtaining the Equipment or part funding from any other source ( eg NHS Wheelchair Services, Social Services, Local Health Authority, Motability or other Charity or Trust etc )
If yes - please give details of whom you contacted and whether they were able to assist you or not
APPLICATION SUPPORT  
If you are on a spinal centre, you are required to ask the appropriate Medical Specialist ( Occupational Therapist, Physiotherapist or Consultant ) responsible for your treatment and rehabilitation, to sign a Statement of Consent ( Below )

If you have left the Spinal Centre , you must obtain the signature of a Medical Specialist who understands your personal requirements

" I support this application for the equipment requested which in my opinion will improve the applicant's quality of life"
Signed ( Type name to sign )
Date
Print Name
Title
Work Address
Postcode
Work Telephone Number
REGAIN WILL NOT PROCESS AN APPLICATION WITHOUT THE SUPPORT OF A MEDICAL SPECIALIST  
Signature of Applicant - I confirm the above is true and accurate
Date :  
Can you make a contribution towards the cost of this equipment ?
( We do expect ALL applicants tocontribute towards the cost )  
Have you provided 2 quotes from supplies plus supplier details ?
FINANCIAL  
Please explain your Financial Circumstances ( eg Income support / pension / full or part time employment )
Have you received a compensation claim ?
If so how much and when ?
Have you a compensation claim pending ?
Are you in receipt of DLA ?
Do you own your own home ?
Do you own /control or have access to other significant assets ( eg property / shares / private pension etc )
If yes please give details
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