AMBER Music Award Scheme

Registered Charity No 1050503

APPLICATION FORM

PLEASE COMPLETE ELECTRONICALLY OR WRITE LEGIBLY

For assistance, please contact Prof. Adam Ockelford on 07818 456472

or e-mail

Child’s/Young Person’s Name
Date of Birth / Male or Female / Parent’s/Primary Carer’s Name
Mr/Mrs/Ms/Miss
Address (with postcode) / Telephone numbers:
Daytime
Evening
Mobile
E-mail:
School your child is attending
Please tell us the diagnosis of your child’s visual impairment as well as any other disabilities and how he/she is affected:
Please explain what you are seeking funding for:
Please outline the child’s previous experience of music and current level of ability:
What impact would this AMBER Music Award have on the child?
If you are applying for music lessons or music therapy sessions, when are they planned to start? (AMBER Music Award meetings take place in March, July and November each year so this date should be from the next month/term onwards)
How much funding is requested? (A quotation for costs from the teacher/therapist/supplier must be enclosed with this application with details of the hourly rate and length of music lessons/therapy sessions)
Please give the Teacher’s / Therapist’s / Supplier’s contact details
For Teachers or Therapists, please give qualifications and/or relevant experience
Does the Teacher or Therapist have CRB clearance (required)? Please give details
Have you looked into sources of statutory or other funding? If yes, from whom and what was the outcome?
If the application is for music therapy, is this included in your child’s Statement of Special Educational Needs? Please give details
I am / am not happy for The AMBER Trust to use my child’s story and/or photograph on our website or in any of our publicity material: (please delete as appropriate)
How did you hear about The AMBER Trust?
From the AMBER Website, RNIB or ‘other’ - please state:

I declare that the information I have given on this form is correct and complete.

Signature of Parent/Carer:

Print name: Date:

Details of any additional contact for this application:

Name:

Role:

Relationship to the child/young person:

Address (including postcode):

Telephone number(s):

Email:

Please send your completed form with a quotation for the costs to:

The AMBER Trust, 41 Brighton Crescent, Bristol, BS3 3PP

or e-mail to