Thursday 29 July 2010
All applications must be supported by a recognised sports club, sports body, school or spinal unit. Please complete this form after you have read the guidelines.
Title
First Name
Surname
Address
Post Code
Daytime Tel
Mobile Tel
Email
Date of Birth
Please give a brief description of your previous sporting participation:
Supporting Body
Contact Name
Position
Relationship to applicant
Organisation Address
Correspondence Address
Telephone
Mobile
The Wheel Appeal will provide successful applicant with either a 'standard' manual sports wheelchair or a grant towards a bespoke sports wheelchair (up to a maximum value of £1,500 excluding VAT). All payments will be made directly to the wheelchair supplier.
What sport(s) do you need a wheelchair for
Application type Standard Wheelchair Bespoke Wheelchair Grant
If you are applying for a grant towards a bespoke wheelchair, please complete Section Four, otherwise, go to Section Five
Grant requested
Total price of chair
Do you currently play sport? Yes No
Do you own a sports wheelchair? Yes No
If yes please give details of why you need a new chair/replacement (eg different sport, broken, currently use borrowed chair)
Have you applied to any other organisation for a wheelchair? Yes No
Please give us the details, including date, amount, which organisation and outcome
Have you applied to WheelPower for a grant before? Yes No
Was your application successful? Yes No
How much were you awarded?
Please provide any additional comments relevant to your application:
There are a number of ways you and your family can support the Wheel Appeal or get involved in our work. Please read this section and tick any areas which might be of interest.
I would like to represent the Wheel Appeal in my local area Making a donation Making a regular donation by Direct Debit Join a Give As You Earn scheme at your workplace Entering a race eg London Marathon Fundraising locally Doing a parachute jump Learning how my company can support Wheel Appeal Fundraising at my School/college Leaving a gift in my Will
Please provide information about your disability
This section will help us to monitor our service and ensure we reach all sections of the community.
Please select your ethnic origin from ths list I do not wish to declare my Ethnic origin White - British White - Greek White - Jewish White - other Asian - Indian (inc British Asian) Asian - Pakistani (inc British Pakistani) Asian - Bangladeshi (inc British Bangladeshi) Asian - other Black - British Black - Caribbean Black - African Black - other Chinese (inc British Chinese) Chinese - other Mixed Heritage - White and Asian Mixed Heritage - White and Black African Mixed Heritage - White and Black Caribbean Mixed Heritage - other Any Other Ethnic Background
How did you hear about the Wheel Appeal? (tick all that apply)
Advert Internet search Local radio station or newspaper article Spinal Unit Sports Club or Association WheelPower website Word of mouth Other
We would like to keep you up to date about our work and activities. If you would prefer not to receive this information, please tick here
One of the easiest and most effective ways to help us help you is to give consent to use information about you in various awareness raising and fundraising activities. If we are to continue our work and help many disabled people we need to be able to demonstrate the impact of our work through a variety of case studies.
By submitting an application, you consent to WheelPower using the information in this application for our publicity and campaigning work, including printed materials, on our website, in the media, as well as to provide information for current or potential fundraisers/donors that support our work.
By submitting this application, you agree to the Wheel Appeal Terms & Conditions
Action