APPLICATION FORM FOR

 

DOUGLAS HAY TRUST FOR CRIPPLED CHILDREN

COMMONLY KNOWN AS THE DOUGLAS HAY TRUST

SCOTTISH CHARITY NUMBER SC014450

 

 

DATE:

CHILD’S NAME:                                                                                    D.O.B:

PARENT’S NAME:

ADDRESS:

 

PHYSICAL INCAPACITY:

 

 

NAME & ADDRESS OF DOCTOR:

 

 

Is this your first application                          YES

 

NO

 

Please tick appropriate box

If No – Please state date of previous application:

How many other children are there in the family:

The grant is require to purchase:

(State if Clarks shoes required)

At the approximate cost of:

Family Income (weekly)

Family Expenditure (weekly)

 

 

 

 

 

 

NOTE: If on Social Security; no other details are required

 

THIS SECTION MUST BE COMPLETED OR THE APPLICATION WILL BE RETURNED

Name of Organisation/Social Work Dept cheques are made payable to: – not required for shoe vouchers:

………………………………………………………………………………………………………………...

PLEASE RETURN COMPLETED FORM TO

DETAILS OF SPONSOR/SOCIALWORKER

JD Ritchie CA Treasurer

The Douglas Hay Trust

Barstow & Millar CA

Midlothian Innovation Centre,

Pentlandfield, Roslin,

Midlothian EH25 9RE

Tel: 0131 440 9030

Fax: 0131 440 9872

e-mail: enquiries@barstowmillar.com

Web: www.douglashay.org.uk

NAME:

 

POSITION:

 

ADDRESS:

 

 

TEL:

e-mail:

 

SIGNATURE: