These Sections to Be Completed by Patient / Parent

Annabelle’s ChallengeGrant Application Form

These sections to be completed by patient / parent:

Date of Application
Patient Details
Full Name
Date of Birth
Address & Postcode
Telephone
Email Address
Please sign to confirm your application and acceptance of our terms and conditions detailed below
If your claiming for a child under the age of 16 please confirm your name & relationship / Parent / Guardian / Carer
Diagnosis Confirmation
Date Diagnosed
EDSDiagnostic Service who provided your diagnosis (Please circle) / London / Sheffield
If NOT diagnosed by the EDS Diagnostic Service please specify which NHS hospital / Genetics Clinic
Your GP’s name and address
Please specify which NHS Hospital you are using for your ongoing appointments
Reason for claiming this grant
Please specify the amount of funding required / £
Please specify information about how the amount of financial support requested has been estimated EG:
“14 visits by car to St Thomas Hospital (a 30 mile round trip) over a twelve month period” or • “A family weekend break in Wales for three nights in July at a cost of £X per person for accommodation and £X per person for travel” or • A fuller picture of the item being purchased and it’s positive affect on the patient diagnosed with vascular EDS.

ONLY COMPLETE THE SECTION BELOW IF YOU DO NOT HAVE YOUR NHS DIAGNOSTIC LETTER ATTACHED TO THIS APPLICATION. Please note we may contact your GP / hospital to confirm your details & diagnosis.

Authentication by your medical professional
I confirm that the patient in this application has been diagnosed with vascular Ehlers-Danlos syndrome on or after 1st May 2014.
Full Name
Signed
Please confirm your position (Doctor, Consultant or Genetic Counsellor)
Your address & postcode
Date
Terms and Conditions
In submitting this application Annabelle’s Challenge charity will process (in confidence) this information to the board of trustees for their consideration. A copy of the patient’s diagnosis letter must be submitted with this application, if you are unable to find your letter we will contact your genetic counsellor.
This process will take around four weeks from initial application.
Award amounts will vary depending on circumstances and needs but the average grant amount will be £250. Higher amounts are available subject to board approval, the board meets every quarter and the amount available for grants each financial year is restricted.
Each application is individually assessed on its own merits and all information provided is fully considered. The decision by the trustees will be final.
Please note: The request for financial support must always demonstrate a clear connection between a financial need and the impact of vascular Ehlers-Danlos Syndrome on the patient and their immediate family.

Please email this application with a copy of your NHS diagnostic confirmation letter to or post to: Annabelle’s Challenge, Europa House, Barcroft Street, Bury, BL95BT.

Registered Charity No. 1157074

To be completed by the board of trustees:

Application: Approved / Declined Date:

Amount Awarded: £

Diagnostic Letter Attached: Yes / No (If No do not process until confirmed by GP or Genetics)