Therapy Funding Application

Support4SDR Wales raises funds to help families living in Wales to pay the costs of private therapy and training before and after SDR surgery. The amount of funding we are able to distribute will vary each year depending on how much money we raise and the number of applicants. The allocation may vary depending on the costs of the therapy specified. Funds will be allocated to all eligible applicants on a first-come-first-served basis and any eligible applicants not receiving funds in the first year will be prioritised in further funding rounds. The therapy or training provider will be required to send an invoice to Support4SDR Wales to receive payment. 

If you wish your child, or yourself, to be considered for funds to cover a block of therapy please complete Part A below, which includes your contact details and information about you or your child. Please also fill out Part B about the aims of the therapy or training that you have chosen.
 
On receipt of your application, if your chosen provider is not registered with us we will send them a form to complete before we are able to agree any funding. This is to ensure that all necessary insurances, qualifications and checks are in place. We will keep all information strictly according to data protection rules and not share any information with any third party under any circumstances.
 
In submitting this application you are also agreeing to complete a questionnaire after your training or therapy so that we can collect information on outcomes and the progress made. This will help us to meet our success criteria as a charity and thus to apply for more funds on your behalf. Filling in a completion form is a condition of future funding. All information on outcomes will be anonymised

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* 1. Applicants Name (the person who will receive the therapy)

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* 2. Date of birth

Date

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* 3. Parent/Guardian's name (where applicable)

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* 4. Current address

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* 5. Phone number

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* 6. E-mail address

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* 7. Local Health Board Name

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* 8. Date of SDR surgery or planned date

Date

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* 9. Form of Cerebral Palsy

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* 10. Gross Motor Function Classification Score (if known).  More information at http://motorgrowth.canchild.ca/en/gmfcs/resources/gmfcs-er.pdf

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* 11. Proposed therapy provider

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* 12. Description of the therapy, including number of hours and timeframe

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* 13. Total cost of therapy required

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* 14. What are your aims to achieve from this therapy?

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* 15. How do you feel this  therapy will contribute towards the applicant's well being?

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* 16. Email address

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