Grant Application

Please take your time while filling out this application

Applicant

Amount Being Sought*

Full Name*

Email*

Mobile*

Address

Post Code*

Relationship to Beneficiary*

Beneficiary

Full Name*

Referee / Organisation (e.g. GP/PHN/SOCIAL WORKER)

Name of Referee / Contact*

Name of Organisation (if applicable)

Address*

Phone*

Email*

Information

Have the BENEFCIARY ever received a grant from the QIDN before?*

Type*

Date*

Amount*

In relation to the support, equipment, relief or care being sought in this application, has an application been made to or grant received from the HSE or other source?*

Type*

Date*

Amount*

Supporting Information

Please supply a quotation from two different suppliers and a declaration of support by a health professional or social worker with this form*

Please attach any other supporting document with this form

Please select one of the following:

If you are the "APPLICANT" applying on your own behalf, please tick the boxes below:
I have read the terms and conditionsI have read and accept the privacy policy

If you are the “REFEREE” applying on behalf of the “APPLICANT” please tick the boxes below:
I confirm that the applicant has read the terms and conditionsI confirm that the applicant has read and accepts the privacy policy