How to Apply

An application form is available to fill in below.

Alternatively, you can access a hard copy/PDF to print and fill in manually here, or from Bungay Medical Centre, 28, St John’s Road, Bungay, Suffolk, NR35 1LP . Please send it by email to profchhand@gmail.com or by post to Professor Christopher Hand, The Pines, Mettingham, Bungay, Suffolk, NR35 1TD

Please try to complete as many sections as possible of the application form. If you have any emails, letters, or brochures that you feel would help please send copies with your application. You can also send a supporting letter from a healthcare professional if they wish to provide one – they are not obliged to do so.

Part One of the form shows your name and address and will only be seen by the Trustee who administers the grants. The other trustees will see the information you provide in Part Two of the application but will not be told your identity.

See our Privacy statement for more information about how we look after information you give us.

Part 1
A. Beneficiary Details (the person who will receive the grant)

Name:

Address and Postal Code:

Telephone Number:

Email address:

Age:

B. Person making the application (if the beneficiary is unable to apply themselves)

Name:

Address and Postal Code:

Telephone Number:

Email address:

Relationship to Beneficiary:

Part 2
A. Why are you applying for a grant?

What is it about your current health and financial circumstances that merit a charitable grant?

B. How much money are you requesting and what is the grant to be used for?

If equipment is asked for, please provide a description of the equipment, the manufacturer and the model, including cost, VAT, and costs of delivery and installation.

C. Improvement to your daily Life

What difference would the grant make to your life and your family’s life? For example, what would you be able to do, that you cannot do now?

Where did you hear about the Bungay Medical Centre CIO?

Declarations

I , the beneficiary, declare that:
1. I am not receiving funds for this purpose from another source
2. I would not be able to fund this requirement from my own resources
3. The evidence I have given in this grant application is factually correct.

Acceptance of Declaration

The Bungay Medical Centre CIO provides grants for people in Bungay and nearby who have a medical need. Typical grants might include support for mobility aids, stair lifts, home improvements, medical equipment and travel and accommodation when people have to visit hospitals across the country.

Download Application Form