Emergency Fund Form

Use this form to apply for the Hugh James Emergency Fund to assist the family of those suffering catastrophic injury spend more time with them.

"*" indicates required fields

About the person who has sustained the catastrophic injury

Injured person's name*

First name

Surname

Injured person's address*

Address line 1

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?*

About the person who will receive the grant

Contact's name*

First name

Surname

Contact's address*

Contact's mobile telephone number*

Contact's relationship to the person with the injury*

Professionals / clinicians applying on behalf of someone else

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

Name of person completing the form*

First name

Surname

Employing organisation of person completing the form*

Job title of person completing the form*

Address of person completing the form*

Work phone number of person completing the form

Email of person completing the form*

Individuals applying on behalf of someone else

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

Name*

First name

Surname

Employing organisation

Address*

Mobile telephone number*

Work telephone number

Email*

Reasons for applying for emergency funding

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

Amount required*

Source of information

Where did you hear about the Emergency Fund?*

Please specify*

Further advice and support

Please contact me for a free consultation*

Delcaration

I hereby give consent to 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.*

CAPTCHA

Hugh James Emergency Fund Application Form