Emergency Fund Form

Hugh James Emergency Fund Application Form
029 2267 5870

029 2267 5870

Emergency Fund Form

1 About the person who has sustained the catastrophic injury

Injured person’s first name *

Injured person’s Surname *

Injured person’s Address line one *

Injured person’s Postcode *

Injured person’s Date of birth *

Cause of injury

Date of injury

Injured person’s Occupation *

Injured person’s Nationality/language spoken *

Is the person who sustained the injury currently in hospital or rehabilitation?

What type of injury has been sustained?

Next: About the person who will receive the grant

2 About the person who will receive the grant

Contact’s first name *

Contact’s Surname *

Contact’s Address line one *

Contact’s Mobile telephone number

Contact’s Postcode *

Contact's relationship to the person with the injury

Next: Professionals / clinicians applying on behalf of someone else

3 Professionals / clinicians applying on behalf of someone else

Are you a professional or clinician submitting this form on behalf of someone else?

Forename of person completing form

Surname of person completing form

Employing Organisation of person completing form

Job title of person completing form

Address Line 1 of person completing form

Postcode of person completing form

Work number of person completing form

Email of person completing form

Next: Individuals applying on behalf of someone else

4 Individuals applying on behalf of someone else

Are you an individual submitting this form on behalf of someone else?

Forename (non CRM)

Surname (non CRM)

Employing Organisation

Address Line 1 (Non CRM)

Postcode (Non CRM)

Mobile telephone number

Work number

Email (Non CRM)

Next: Reason for applying for emergency funding

5 Reason for applying for emergency funding

Please explain why the grant is required. This should include information about the financial situation *

Amount required *

Next: Source of Information

6 Source of Information

Where did you hear about the Emergency Fund? *

Solicitor
Website
Google
Charity
Other

Next: Further advice and support

7 Further advice and support

Please contact me for a free consultation

Next: Declaration

8 Declaration

I hereby give consent for Hugh James to contact relevant medical professionals, legal representatives and other appropriate organisations on my behalf in order to verify the information provided on this form, as well as to request other assistance which would be beneficial to the person with a brain injury. *

If a charity has helped you to apply for an Emergency Fund payment, are you happy to consent to details of the payment being shared with the charity which has supported you?

I declare that the information provided above is true and accurate and that the person requiring help is in genuine need of emergency funds. *

Hugh James Emergency Fund Application Form