Application

Please complete every applicable section. Enter “N/A” where a question does not apply.

The trustees means-test all applications and assess them using a point-scoring system. For equipment requests, please attach a description and quotation wherever possible.

1. Applicant details

Your full name *

Email address *

Address *

Postcode *

Home/mobile number *

Have you applied to us before? *

Yes No

Was the application successful?

Approximately when did you last apply?

Are you a British citizen? *

Yes No

Have you lived in the UK for the last six months? *

Yes No

Please give details

2. Child or young person's details

Child's full name(s) *

Date of birth *

Condition or diagnosis, if known *

Date of diagnosis, if known

DLA/PIP received and rate(s)

Education and support plans

Statement of SEN

Yes No

Coordinated Support Plan (CSP)

Yes No

Education, Health and Care Plan (EHCP)

Yes No

Individual Education Plan (IEP)

Yes No

Professional who knows the child well * Please include the name, role, organisation, telephone number and email address of a social worker, key worker, lead professional, health visitor, teacher or similar person—not the child's GP.

3. Your request

Item(s) or support required *

Cost, if known

Supplier, if known

How will this benefit or improve the child's daily life? *

Have you applied elsewhere for this specific item or support? *

Yes No

Which organisation(s)?

What was the outcome?

4. Household and means test

Accommodation type *

Local authority rented Owner occupied Private rented Housing association Other

Accommodation status *

Temporary Permanent

Total savings

Household income

Enter the amount actually received and choose how often it is received. The form converts each entry to a monthly equivalent.

Income source	Amount	Frequency
Total household wages, sick pay, maternity allowance, JSA or incapacity benefit
Working Tax Credit / Universal Credit
Child Tax Credit
Child Benefit
DLA / PIP
Pension Credit
Maintenance
Housing Benefit

Household outgoings

Enter essential household expenditure and select how often each amount is paid.

Outgoing	Amount	Frequency

Monthly household income £0.00

Monthly household outgoings £0.00

Monthly amount remaining £0.00

5. Benefits and supporting documents

Please provide your latest benefit award letter, dated within the last 12 months, where applicable. Bank statements must be less than three months old. Please do not send original documents.

Your chosen form service or web host must support file uploads. Maximum sizes will depend on that service.

6. Photograph permission and declaration

Name of person in photograph

Age

I give Make Them Smile permission to use the submitted photograph(s) to support and promote the charity.

Where did you hear about our charity?

Name of main carer/applicant *

Electronic signature *

Date *

7. Final checklist

I have completed all applicable sections. * I have attached supporting documents. * I have attached bank statements for all accounts. * I have attached photographs, where applicable. I have attached quotations, where applicable.