Scottish Huntington S Associationyouth Project (SHA) Will Consider an Application for A

Scottish Huntington’s AssociationYouth Project (SHA) will consider an application for a grant to assist with the costs of a day out or towards a holidaywherethe following criteria are met:

the applicant is :

a person living with Huntington’s disease (HD)
a carer of a person living with HD
a young person (up to 25) living in a family affected by HD
a guardian of a young person (up to 25) living in a family affected by HD

AND

the money will be used towards a family, sibling group or equivalent (where at least one person is aged under 18) dayout/ holiday.

How to apply

Please complete this application form (keeping a copy for your own records) and return to us at the address at the bottom of this page. Please note that we cannot fundrequestsretrospectively, or where a deposit has been placed. Do not place deposits inexpectation of a grant, as grants can never be guaranteed and you may lose your deposit.Your application will be considered in the strictest confidence.

If you have any queries regarding your application, then please contact us at:

SHAYPFamilies Getting 2Gether

Scottish Huntington’s Association

Unit 2a David Dale Business Centre

159 Broad Street

Glasgow

G40 2QR

Tel:0141 556 2136/ 07983 724201

E-mail:

Kindly funded by

Part 1About you (the applicant)

Title / -
Given name(s) / -
Surname / -
Date of birth / -
Age / -
Address / -
Postcode / -
Telephone / (home) / -
(mobile) / -
E-mail address / -

For the following questions, please tick the appropriate box :

Are you a member of SHA? / Yes ☐ / No ☐
Have you been diagnosed with HD? / Yes ☐ / No ☐
Are you a carer of someone living with HD? / Yes ☐ / No ☐
If yes, what is your relationship with that person?
(e.g. spouse, family member, paid carer, etc.)
Are you a young person living in a family with HD? / Yes ☐ / No ☐
Are you a guardian of a young person living in a family with HD? / Yes ☐ / No ☐

Part 2About your application

(Important : providingas accurate a cost of your break as possible will make it more likely that the Grant Committee will be able to assist)
How much would you like to apply for (the maximum grant is £20 per person attending the day out/ holiday)? :
What is the total expected cost of your day out/ holiday? :
How will you fund the remainder? (if applying for a grant less than the total cost) :
Where will you be going on your day out/ holiday? :
When will you take your day out/ holiday? :
Who will be going on your day out/ holiday? :
Name / Age / Relationship (e.g. self, daughter, etc.)

Part 3Additional information (optional)

Is there any additional information that you would like us to take into account when considering your application? :

Part 4Independent letter of support

Where you are currently not receiving support from either SHAYP or an HD Specialist an independent letter of support from a professional e.g. teacher, social worker, GP must be included.

Part 5Data protection

SHA, its employees and volunteers will keep your personal details secure. The information given on this form will be used solely for the purpose of considering your application. It may be necessary for us to contact your HD Specialist, health or social care professional in relation to your application.

Declaration

I, the applicant, agree that any grant awarded will be used solely for the purposes for which it is intended; the proceeds, of which, to be used by 01-11-2015 (as stated on the award letter).

I also agree to complete a short evaluation following the day out/ holidaythat describesmy/our short break and the benefits realised.

If you are the applicant, please complete Part (a).

If you are completing this form on behalf of the applicant, please complete Part (b).

Part (a)
Please print name / -
Signature / -
Date / -
Part (b)
Please print name / -
Relationship to applicant / -
Address (if different from Part 1) / -
Postcode / -
Signature / -
Date / -

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