PERSONAL DETAILS

Your Name

Age

Address

Contact No.

Your Email

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 )
yesno

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 of Injury

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

Confirm date of signature

Can you make a contribution towards the cost of this equipment ?
( We do expect ALL applicants tocontribute towards the cost )
yesno

Have you provided 2 quotes from supplies plus supplier details ?
yesno

FINANCIAL

Please explain your Financial Circumstances ( eg Income support / pension / full or part time employment )

Have you received a compensation claim ?
yesno

If so how much and when ?

Have you a compensation claim pending?
yesno

Are you in receipt of DLA ?
yesno

Do you own your own home ?
yesno

Do you own /control or have access to other significant assets ( eg property / shares / private pension etc )
yesno

If yes please give details

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