Apply for a Grant

Application form

PERSONAL DETAILS







INJURY DETAILS









EQUIPMENT / GRANT REQUEST







yesno



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"








REGAIN WILL NOT PROCESS AN APPLICATION WITHOUT THE SUPPORT OF A MEDICAL SPECIALIST


I confirm the above is true and accurate



yesno


yesno


FINANCIAL



yesno



yesno


yesno


yesno


yesno


 

Notes

Please complete the application form to apply for a grant from Regain.

Accompanying letters should be e-mailed to enquiries@regainsportscharity.com or posted to :

Ann Frampton, House of St Francis, Whitwell, Isle of Wight, PO38 2QX