Challenging MND – Grant Application

Please note, during this form you will need to upload files to support your application. These are:

A scan/image showing proof of the diagnosis of MND in letter format from the Neurologist
Scans/documents outlining the costs and official quotes from supplier(s) in relation to the requested grant

Name of beneficiary

Beneficiary Date of Birth

Beneficiary Email Address

Beneficiary Phone Number

Address

Town / City

County

Post Code

Person applying

I am the named beneficiary

I am applying on behalf of the above named beneficiary

Relationship to beneficiary

Applicant email address

Are you a clinician making the referral?

Yes

No

Clinician job role

Clinician workplace

Description of what the grant is required for

Copy of letter from Neurologist on NHS headed paper confirming diagnosis of MND

Maximum file size: 10MB

Quote from supplier

Maximum file size: 67.11MB

Please provide a scan or copy of the quote from the supplier(s) indicating the costs

Please tick to confirm consent of the beneficiary to share their personal details in the application for a Challenging MND grant

I confirm the beneficiary provides consent for Challenging MND to share personal details in the process of the application

Please note, the consent during the application process must be explicitly provided via email directly from the beneficiary email address, or in a short video call.

Please confirm this is the first application for a grant, and that no prior application has been made by or on behalf of the above named beneficiary

I confirm this is the first application and there have been no prior applications