0800 169 1601
Date of Birth
Parent 1's Name
Parent 2's Name
Resident In UK YesNo
Adaption to home required
How do you expect the above to benefit your child?
We confirm we have explored the possibility of obtaining a Disabled Facilities Grant from our local authority YesNo
We confirm that we have been unsuccessful in such an application YesNo
We confirm we have letters from two healthcare or social work professionals, one of whom should be an Occupational Therapist YesNo
Please attach letter 1
Please attach letter 2
We confirm we have a minimum of two quotations for the work YesNo
Please attach quote 1
Please attach quote 2
We agree to Just4Children providing a surveyor to confirm works are practical and cost effective YesNo
We confirm the Works are commissioned by you, and agree that Just4Children will not be held liable for any costs, actions or claims arising from their installationYesNo
We agree to let Just4Children know if we sell the house within five years, for a value above what the un-adapted property would have been worth, that the difference in value shall be payable to the charity YesNo
If we sell the house within five years for more than its current valuation, we agree to pay Just4Children any amount over that valuation YesNo
Your Target for the above?
Funds raised to date?
Will you give permission for a photograph and details to be used for our fund-raising purposes and the press? YesNo
How did you hear about us?
The above information is true, and I agree not to bring Just4Children into disrepute. We agree that any funds raised over our target may be used for other children. We understand that where possible all monies will be used as directed but where appropriate will be used for general purposes. Accept