Apply for a grant Complete the form below. Please refer to our Frequently Asked Questions before completing the form Your Name * First Name Last Name Email * Phone * (###) ### #### Relationship to the person with FA who will benefit from the grant (the beneficiary) * Please let us know who is applying for this grant Parent Grandparent Spouse/Partner Carer Friend Other Details of beneficiary Only if different from above First Name Last Name Address * Email Only if differnt from above Date of birth * MM DD YYYY What is the total cost? * Plesae give us the total amount you are applying for (travel costs/treatments etc) What will the grant be used for? * Please provide as much detail / specific information as possible If the equipment/treatments exceeds the maximum FAF will award (£5000), please let us know how you will cover these additional costs. Tell us about the beneficiary e.g. * • their likes and interests • their employment / education status • how does FA impact their life Consent * Do you have their consent to apply on their behalf: Yes N0 Please use the box below to provide us with any additional information you want to tell us to support your application (but don't worry if you don't use it!) Thank you for completing the application for a grant from Freddie’s Ataxia Fund.We will be in touch soon.Any additional Information can be emailed to chair@freddiesataxiafund.co.uk
