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 :

    Paul Lawrence, Charity Director, Regain, The Foundry, 17 Oval Way, London, SE11 5RR