Application for Adaptions

    Child Details

    Child's Name

    Date of Birth

    Age

    Medical Condition

    Parent 1's Name

    Parent 2's Name

    Tel. No

    Address 1

    Address 2

    City

    Postcode

    Email

    Resident In UK YesNo

    Occupation

    Parent 1

    Parent 2

    Your GP

    Name

    Address 1

    Address 2

    City

    Postcode

    Phone

    Email

    Your Consultant

    Name

    Address 1

    Address 2

    City

    Postcode

    Phone

    Email

    Adaption Details

    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?

    Terms and Conditions

    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

    Date

    Signed