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Grant Application
Grant Application
Please take your time while filling out this application
Applicant
Amount Being Sought*
Full Name*
Mr.
Mrs.
Ms.
Other
Email*
Mobile*
Address
Post Code*
Relationship to Beneficiary*
Parent
Guardian
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?*
No
Yes
Type*
Home Care
Nursing Care
Medical Equipment
Mobility Equipment
Education
Palliative Care
Respite Care
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?*
No
Yes
Type*
Home Care
Nursing Care
Medical Equipment
Mobility Equipment
Education
Palliative Care
Respite Care
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 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 conditions
I 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 conditions
I confirm that the applicant has read and accepts the privacy policy
Submit
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