To be retained for your reference purposes. Equipment Grants Newlife funds a wide range of essential equipment including specialist seating, wheelchairs, beds and communication aids. We will consider funding computers/portable tablets if it is necessary to manage the child/young person s inability to verbally communicate. We will assess if we can help by considering the impact on the child/young person s health, quality of life and safety. We will also assess the impact of inappropriate or no provision on the parent/carer s ability to support the child/young person s daily care needs. This assessment will help us define whether the equipment is essential. If we award a grant we will place the order, arrange delivery and, where possible, installation. Training on how to use the equipment (if necessary) is carried out by the supplier or supporting local professional. Families can indicate the type of equipment needed. But a supporting professional must provide details of the specification. For operational reasons, we cannot fund adaptations to cars or properties, therapy/treatment costs, white goods and holidays. All our grants are for the benefit of an individual child/ young person. We cannot provide equipment for group use. If you need any of these types of support, please call our National Nurse Helpline and we may be able to signpost you to another organisation. You can apply for equipment through any of our grant and loan services as often as your child/young person requires essential equipment to meet their specialist needs. Application Assessment All applications are reviewed by a Newlife Nurse upon receipt. They use their skills and paediatric experience to assess the urgency of need. If they believe the need is urgent, they can Fast-Track the application so that funds are committed to help on the same day as receiving the application. If the application does not need to be Fast Tracked, we will identify an appropriate time period during which we will look to secure funding from supporters and local NHS and Social Care services. We will let you know our decision usually within two weeks of receiving your application, dependent on demand for our services. Equipment Grant Application Form Page 1 of 18 Application Outcome We will normally write to you (ideally using a given email address) to inform you of one of the following three outcomes: Outcome 1 - The funding is agreed, the equipment is ordered, and a delivery date will be provided. The applicant becomes the owner of the equipment, once Newlife receives acknowledgment of delivery, and subsequently is responsible for the maintenance of the equipment in line with the manufacturer s recommendations. For complex equipment, such as powered wheelchairs, the suppliers often offer a package at a flat fee to cover this, for which the owner will be responsible to fund. In the case of wheelchairs, if the local wheelchair services department offers vouchers towards the cost, they may agree to be responsible for maintenance. Outcome 2 - We will give you an In Principle decision that we agree there is an essential need for the equipment and we will look to secure funding by a specified date - determined by the information within the application form. We do not receive government funding, and are heavily reliant on community fundraising support. Outcome 3 - If, after due consideration, we find that we are unable to award a grant, we will write to you as soon as possible so that you can make an application elsewhere. Newlife Nurses may be able to give you information about other organisations or services that could help. To appeal the outcome, or complain about the application process, please email the Senior Care Services Manager at carrickbrown@newlifecharity.co.uk who will report it to the governance department, and periodically to the trustees, while trying to find a compassionate resolution.
Equipment Grant Application Form Managing Your Information Equipment Grant Application Form Page 2 of 18 Newlife can help you in many ways, If you would like to know more about what we do, access this support, or help us in other ways that could help change the lives of disabled children and their families then please tick the relevant boxes below. The permissions associated within this section managing your information refer to the applicant s details rather than anyone else referred to in the application. Do you agree to receive additional information about Newlife s Care Services? If Yes, we will contact you initially to provide details about all of our Care Services and then as we develop and update each individual service. Do you agree to Newlife providing the child/young person s name, age, residential county and description of their condition and reason for why you need the equipment to donors and supporters to demonstrate how equipment can change young lives demand for services and encourage financial donations? If Yes, we will share this information because we know that our supporters are inspired to help again when we tell them about the children we have helped. So it s important, that we can share some basic information. This is common with most charities who are highly dependent on the public to help them meet the needs of children and their families. Do you agree to provide a photo of the child/young person that could be used to highlight their specific need for the equipment within this application? If Yes, please note that this can be sent by email to feedback@newlifecharity.co.uk or by Royal Mail standard delivery. Following receipt of your application, would you be happy to speak to our media team to explore using the press to raise funds for the equipment? If Yes, we may be able to improve the likelihood of funding the grant by appealing for support through your local press. You can expect the media team at Newlife will call you to discuss generating and sharing a media story about the child/young person s need for the equipment and help provide funding for the equipment earlier than if it was not undertaken. Please note that the use of your child s photograph is a pre-requisite of use in local media. Your local community may be able to raise funds for the equipment. Would you be happy to speak to our fundraising team for more information and support to fundraise for the equipment requested in this application? If Yes, there are many different ways we can support you to build up donations towards funding this equipment. Our fundraising team would be happy to share their experience with you and support any future fundraising activities relating to this application.
Equipment Grant Application Form Page 3 of 18 If a grant is awarded as part of this application, and following subsequent delivery of the equipment, do you agree to us contacting you to gather feedback on the service you received and difference made by the provision of the equipment? If Yes, Newlife will email or telephone you three months after equipment has been provided. If a grant is awarded as part of this application, and following subsequent delivery of the equipment, do you agree to speak to our media team to help raise awareness of Newlife s services and to help other children in need. If Yes, our media team will contact you once the equipment has been delivered to find out how it has helped the child/young person and if appropriate, your family as a whole. If you wish to help us develop a media story for awareness or fundraising purposes, the media team will seek additional permissions. Would you be interested in speaking to our fundraising and volunteering teams about wider opportunities to support the charity? If Yes, as fundraising and volunteering opportunities arise, we will contact you to see if you would like to offer support; on average this would not be more than five times a year. Do you consent to the data provided in this application to be anonymised (removal of all personal data) and analysed for the purpose of research and reporting on the work of the charity? For all the questions above where we ask you if you are happy to be contacted by a Newlife department other than Care Services, please specify your preferred method of contact: By post By email By phone Name Signature Date We, Newlife the Charity for Disabled Children, are the Controllers of the personal data and health information we collect. We need to collect and process certain information to allow us to provide any of the named Care Services below. To see Newlife s full privacy notice, please visit http://newlifecharity.co.uk/docs/general/resources-and-documents.shtml
Equipment Grant Application Form Who Is Completing This Form? Equipment Grant Application Form Page 4 of 18 This form should be completed by someone with parental responsibility and/or the main carer of the child/young person who needs equipment. However, if a child/young person aged 12 or over wishes to be treated as the applicant and is usually regarded as capable of making decisions associated with their own care i.e. they have the mental and emotional development to make sound decisions, then Newlife commits to treating this child/young person as the applicant within the application for equipment. As the applicant, please state if you are the: Parent/Main Carer Child/Young Person If the child/young person is to be contacted directly regarding this application, please still complete the section below to provide parent/carer details so that they can be informed and involved in future communications. If the recipient Child/Young Person is not the applicant, what is the relationship of the applicant to the child/young person? Parent/Carer s Details The details given below should relate to someone to whom the equipment ownership can be transferred if Newlife can provide the grant and order the equipment. Ownership will be transferred upon receipt of the equipment being acknowledged to Newlife. Title Mr Mrs Master Miss Ms Dr First Name Family Name House No. & Street Town County Postcode In order to progress this application you need to give a daytime telephone number and email address that you check regularly. The other numbers are useful for ensuring timely provision of equipment. Tel (daytime): Tel (home): Can you speak English? Tel (mobile): Email: Your preferred language: Have you previously used any of Newlife s services? If No, please tell us how you heard about Newlife: Professional The Media Publication/Leaflet Internet Exhibition Other (please specify) Is the child/young person living at the same address as you? If No please explain further:
Equipment Grant Application Form Page 5 of 18 Is the equipment requested, for use at a different address than the child s home? If Yes please provide the address: Does your child/young person live in a: House Bungalow Flat/Apartment Other (please specify) Is this property: Rented Owned by you/your partner Other (please specify) How would you describe the child/young person s family situation? Living with both parents (include step-parents) Living mainly with one parent Living with care given, at different locations, by both parents Other (please specify) Has your home been adapted to meet the child/young person s needs? t applicable Who in the household, where the child/young person lives, is currently in employment (exclude brothers and sisters) and state if full or part-time: In providing this information, our Newlife Nurses will consider the financial impact on the household of privately funding the equipment. Are there any other children or siblings of the child/young person, living in the same home? If so, please give their gender, age and state if they have any significant health problems or disabilities: In providing this information, our Newlife Nurses will consider the implications of provision on other children/siblings. As the child/young person s main carer, are there any health problems, disabilities or mental health issues, which affect your ability to provide care? e.g. back problems, etc. Please provide as much detail as possible as Newlife s Care Services consider the holistic difference that equipment provision makes, to the main carer ability to deliver care, to be important.
Equipment Grant Application Form Page 6 of 18 Have you received a Carer s Assessment? If Yes, did you receive any additional care/support following the assessment? By informing us of this information, if you are eligible for a carer assessment but haven t had one, we can provide written information about how gain an assessment. Would you like more information? As the child/young person s main carer, are you receiving any of the following types of support (tick all that apply): Day Respite Night Respite Short Breaks Early Help Portage Family Support Worker Special Needs Groups Holiday Play Schemes We are keen to ensure that parent/carers are accessing appropriate levels of support. As the child s main carer, do you receive: Housing Benefit Council Tax Relief Blue Badge Do you receive DLA (Disability Living Allowance care component)? If Yes, at what rate is this provided? Low Medium High Please describe how the DLA is used on a monthly basis: Do you receive: DLAM (Disability Living Allowance Mobility Component)? If Yes, at what rate is this provided? Low High Please describe how the DLAM is used on a monthly basis: Do you use this to lease a car/other equipment through Motability? If Yes, please specify details:
Equipment Grant Application Form Page 7 of 18 Please state which, if any, benefits you receive and how much? Please include all disability and unemployment related income e.g. Disabled Living Allowance, Carers Allowance, Personal Payments, etc. In providing this information, our Newlife Nurses will consider the financial impact those within your household of privately funding the equipment. Do you have paid carers visit your home to support you in looking after your child/young person? If Yes, how is this care funded:
Equipment Grant Application Form Page 8 of 18 Parent/Carer Demographic Information This information can help us to shape our services and support communities throughout the UK. We may also use information within our fundraising applications to demonstrate the support we provide. Decision to withhold information will not affect the progress of your application. Gender Male Female Prefer not to say Age 0-24 years 25-64 years 65+ years Ethnic background White Prefer not to say Religion or belief English/Scottish/Welsh/NI No religion Islam Irish Christianity Sikhism Gypsy or Irish traveller Buddhism Other religion Any other white background Hinduism Prefer not to say Mixed Mixed ethnic background Judaism Asian/Asian UK Indian Pakistani Bangladeshi Any other Asian background Need Support Or Information? African Want To Speak With A Newlife Nurse? Chinese Black/African / Caribbean/ Black UK Caribbean Any other Black/African/ Caribbean background Other Prefer not to say Newlife s Care Services Team readily use confidential translation services. We want you to feel comfortable when raising sensitive questions or discussing important matters. 0800 902 0095 Arab Any other ethnic group Simply call (free from UK mobiles and landlines) and inform a Nurse of your preferred language. Prefer not to say Child/Young Person s Demographic Information Is the ethnic background, religion or belief of the child/ young person different to the Parent/Carer? Yes No If Yes, please specify: Newlife Nurses will provide caring emotional support and useful information regarding: Access to health & social care professionals. Rights & benefits. Local & national services. Delivery of care in the community. Rare & complex conditions.
Equipment Grant Application Form Page 9 of 18 Child/Young Person s Details This section is designed to capture the details of the child/young person who will be using the equipment following a successful grant. The minimum eligibility requirements for an Equipment Grant - the long-term provision of essential equipment - are that the child/young person is a UK resident, has a significant disability which affects their daily life (including a life threatening/ limiting condition or has been diagnosed as terminally ill) and is under 19 years of age. First Name Family Name Date of Birth D D / M M / Y Y Y Y Gender Male Female Prefer not to say National Insurance Number NHS Number Is the child/young person fostered, placed in a residential school or residential care? Has a public appeal, in the name of this child, been active to fund equipment or other benefits, in the last two years? Is the child/young person subject to a Medical Negligence Claim or Award? If Yes, have payments for medical compensation been received or being sought? Does the child/young person receive continuing health care (CHC) funding? If they are old enough to do so, can you describe how the child/young person gets about? If too young to move around independently, do not select an option. Walk unaided Walk using aids Unable to walk Crawl Other (please specify): Can the child/young person maintain head control by themselves? Can the child/young person bear their own weight? Partially Does the child/young person have: (please tick all that apply and provide details regarding the severity to which they affect daily life) Any spine, limb or hip problems, which affect their walking or sitting? Poor muscle control in any part of their body? To be hoisted to transfer between positions? Any difficulties with breathing? Epileptic seizures? If so, please record the extent to which these are controlled. Any type of digestive, stomach or bowel problems? Problems with their sight? Problems with their hearing? Relevant to their age, does the child/young person have difficulty with: Speech? Toileting? Sleeping? Understanding danger?
Equipment Grant Application Form Page 10 of 18 Would you say, or have you been told, your child has a problem with their behaviour? If Yes, please identify if a behavioural management plan has been developed to support the child and give information about how well it is implemented. If deemed relevant to this application, would you be happy to share a copy of the child/young person s behavioural management plan? If Yes, this will be specifically requested and does not need to be provided when submitting this application. Does the child/young person have any allergies or sensitivities? If Yes please list below:
Equipment Grant Application Form Page 11 of 18 Diagnosis And Services Newlife retains the right to capture more information through a short telephone interview if there isn t enough detail provided within this application form, in order to authorise the costs associated with the grant. Therefore, it is worthwhile noting that the quality of information provided in this application form will directly affect the pace at which we can provide the Equipment Grant. Please tell us about the child/young person s condition, diagnosis or disability: Is it considered to be a: Life threatening condition? Life limiting condition? Terminal illness? Please provide additional information to help us understand the cause of the condition, diagnosis or disability: Is your child/young person awaiting hospital admission for surgery or tests? Is the child/young person currently in hospital? Is equipment needed for hospital discharge? If Yes, please provide a discharge date: Don t know Does the child use the services of a Hospice? Does the child/young person attend school? If Yes, what s the name of the school? If old enough to attend school, does the child/young person go to a: Mainstream school Mainstream school and has support/extra/special lessons Mainstream school and uses a special unit Attends a special school Is educated in a different way, please give details: Is the child/young person s education: Independently funded Local authority funded Unsure
Equipment Grant Application Form Page 12 of 18 Does the child/young person have an Education, Health and Care Plan (EHCP)? If Yes, when is it due its annual review: If deemed relevant to this application, would you be happy to share a copy of the child/young person s EHCP? If Yes, this will be specifically requested and does not need to be provided when submitting this application. Which professionals have provided care to this child/young person in the past two years? Please give their role and where possible, details of their employer and the care setting within which they deliver care; e.g. Physiotherapist, funded by NHS, delivering treatment in school. Please give the name of the child/young person s General Practitioner, surgery name, address and their telephone number: Is there currently a Social Worker involved in the child s care? If Yes, please provide contact details: Are there any safeguarding concerns related to this child/young person? If Yes, please give details that are relevant to this application for equipment: If Yes, please state if they are: Current concerns Historical concerns Please provide additional details about the extent to which any current or historical concerns are relevant to this application: As an organisation that isn t directly involved in the child s care, a historical perspective of safeguarding concerns can be helpful when understanding the reason for this application.
Equipment Grant Application Form Page 13 of 18 Please tell us about the equipment that the child/young person currently uses on a daily basis, and how it was funded: Please tell us about the equipment that you hope Newlife will be in a position to fund: What is the brand name/make and model of the equipment needed by the child/young person specified by the named professional whose details you are providing later in the application? Are there any reasons why this application should be considered urgent? Please provide details: When assessing the information within this application, if we feel it is appropriate to provide an emergency equipment loan, can we contact you to discuss using this option? Please tell us how the child/young person is affected by not having this equipment:
Equipment Grant Application Form Page 14 of 18 Please tell us how you believe the child/young person will benefit if they had this equipment: Have you already made an application for this equipment to another charity? If Yes, please state the name of the charity. If you are unsure of the outcome yet please say when you are likely to be informed. We often work with other charities to part fund equipment, so this information is important. Can you make a contribution towards the cost of the equipment? If Yes, how much? Unsure For some pieces of equipment, we will require a minimum contribution towards the overall cost of the equipment. For more information call 0800 902 0095 to discuss your application with us. How do you intend to fund this contribution: Privately/family funded Charity/trust Unsure Would you like to make an additional donation towards the cost of the equipment? If Yes, how much? Have you been told by local NHS and Social Care Services that they will contribute funding towards the equipment?
Equipment Grant Application Form Page 15 of 18 If applying for a wheelchair/buggy, have you been offered vouchers from wheelchair services? If Yes, please provide the name of this service provider and state how much: Have your local Health or Social Care Services offered you appropriate equipment already, which you have not accepted? If so, please state the reason for not accepting: Please identify if there are any reasons why you wouldn t want us to discuss this application with local NHS and Social Care Services: Unless it is clear that it would be detrimental to the child/young person, Newlife routinely collaborates with those organisations that have a statutory responsibility, enshrined in law, to meet the needs of children with disabilities.
Equipment Grant Application Form Page 16 of 18 Supporting Professional s Details Who Is The Most Appropriate Supporting Professional? The ideal circumstances are set out below and will give an idea regarding which organisations should take responsibility for assessing a child s needs. Generally speaking, if the child/young person needs equipment to support their postural needs then the support of an Occupational Therapist or Physiotherapist is required. Medical needs can be supported by Specialist Nurses and Safety/Behavioural needs by Social Workers but they must be appropriately qualified (or supported as part of a multidisciplinary team) to identify the most appropriate specification of equipment. Equipment NHS Employed Professionals Local Authority Employed Professionals Bed Mattress Sleep system Bed surround/side (health) Bed surround/side (safety) Car seat Harness Communication aid Radio aid Visual aid Stair climber Toilet bath/shower aid Standing frame Walking frame Wheelchair accessories Wheelchairs Buggy Buggy weather protection Reins Seating Clothing / bedding Video monitor Shed Mobile hoist Arm support Acheeva In providing the details of a supporting professional providing care to the recipient child, please ensure that the professional named below is aware of your application as they will be needed to complete an additional form that confirms the suitability of the equipment specification and provides information that confirms the child s eligibility for this service. This additional form will be provided by Care Services once this application is received. If you do not have access to the support provided by one of these organisations, we may accept the support of a qualified professional involved in the child/young person s care from education or charitable organisations or following an independent assessment but only if this application is preceded by a conversation with a Newlife Nurse. Simply call 0800 902 0095 to explain the circumstances as to why a local NHS or Social Care Professional can t be named on this application we will offer support to access a service, or agree to alternative arrangements to ensure timely provision.
Equipment Grant Application Form Page 17 of 18 Please be aware that in order to be compliant with the General Data Protection Regulations (2018) then you must have received as a minimum verbal confirmation from the professional, to be named below, that they are willing to have their details shared with Newlife. What is the name of the professional supporting this application? What does this professional do? Who is their employer? What is their telephone number? What is their email address? It is vital that we have an email address for the named professional so that we can share a copy of this form with them, and request an additional form is completed. If this additional form is not completed, an equipment grant cannot be provided. Has this professional been informed that you are applying to Newlife? Has this professional carried out an assessment of the child/young person s needs? Please describe the extent to which this named professional provides direct ongoing support to the child/young person: Following this assessment, has a particular equipment supplier identified an appropriate specification of equipment, and was the professional named above involved in this? Unsure If Yes, please name the equipment supplier and provide the date the specification was agreed. The quote associated with purchasing this equipment, provided at this assessment, must be provided to Newlife. This can be attached to the application when submitted or emailed to careadmin@newlifecharity.co.uk Has this professional carried out a risk assessment regarding use of the equipment?
Conditions Of An Equipment Grant In making this application you are agreeing to: Equipment Grant Application Form Page 18 of 18 1. All the information given in this application process is accurate and representative of the need for this service. 2. Newlife is not obliged to make provision in respect of this application and all grants are at the discretion of Newlife. 3. Newlife may offer new or fully refurbished quality equipment. 4. Any order placed for equipment prior to Newlife committing funds will invalidate this application and any subsequent grant offer. 5. After delivery the named parent/carer within 10 days of receipt of the equipment, sign and return to Newlife the delivery slip provided. Once the acceptance form is received by Newlife, the ownership (title) of the product will transfer from Newlife to the named parent/carer for the sole use of the named child. Any equipment delivered and not signed for as accepted under these, or any other conditions, will remain under the ownership of Newlife and may be recalled at any time. Therefore the applicant is required to sign the equipment acceptance form as soon as possible after delivery and ensure it is returned to Newlife. 6. The equipment requested and supplied must be solely used for the benefit of the child/young person indicated in this application. 7. Newlife accepts no liability for the costs or arrangement of: maintenance, care, adaptation, operation or public liability once the equipment has been accepted by the applicant. 8. Newlife the Charity for Disabled Children are the Controllers of the personal data and health information we collect. We need to collect and process certain information to allow us to provide the requested service. To see Newlife s full privacy notice, please visit www.newlifecharity.co.uk 9. In the process of arranging delivery of equipment, it is implicit that we must share personal information with trusted third-party companies who deliver this service to your home. Our agreements restrict their ability to use this data outside of the intended purpose for which it was provided. 10. The Equipment is provided to you as a charitable act. We will therefore only be responsible for any loss or damage that you suffer in connection with a commitment to fund equipment, to the extent that we are able to claim for such loss or damage under our insurance. Family Declaration By ticking the statements below and signing this form, I (name of parent/carer) agree to the terms and conditions of the grant (as stated above), confirm that the provision is necessary and essential to support the named child within this application, and also confirm that this child meets the following criteria: A UK resident. Has a significant disability which affects their daily life, a life threatening/life limiting condition or has been diagnosed as terminally ill. Under 19 years of age. Signature Date if you have any questions, please contact our CARE services FOR free ON: Lines open Monday-Friday 9:30am-5pm & Wednesdays until 7pm plus 24 hour answerphone (Free from UK mobiles and landlines) 0800 902 0095 Email: nurse@newlifecharity.co.uk Nurse Chat: www.newlifecharity.co.uk/live facebook.com/newlifethecharity twitter.com/@newlifecharity instagram.com/newlifethecharity youtube.com/newlifethecharity Newlife Centre, Hemlock Way, Cannock, Staffordshire WS11 7GF.