PERSONAL DETAILS: CARER

Surname

Christian name(s)

Address

Date of Birth

Your Email

Telephone Number

Are you the primary, unpaid carer of a person named below who is tetraplegic through sporting injury?
yesno

Occupation other than primary career

Occupation before becoming primary career

How long have you been the primary career?

Do you have other people you care for (e.g. children, parents etc).
yesno

If yes, please provide details

When did you last have respite care?

Give brief details

PERSONAL DETAILS: PERSON CARED FOR

Surname

Christian name(s)

Address (if different to above)

Date of Birth

Email of person cared for

Telephone Number of person cared for

INJURY DETAILS OF THE PERSON CARED FOR

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

Which Spinal Injury Centre were you initially treated at?

Which Spinal Injury Centre do you now attend?

Have you ever received support from Regain?
yesno

If yes, please provide details (date, size of grant, nature of grant)

GRANT DETAILS: CARER

Provide a brief description of what you want to do with the grant

When do you want to start using the grant?

Total grant requested

Replacement care

Travel

Accommodation

Other, please specify. Other 1, e.g. gym classes for 6 months / travel insurance /contribution to food

I confirm that above personal information is to the best of my knowledge true and, if awarded, the grant will be spent along the lines set out above.

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