Apply online

Details of the person requiring assistance

• Title: Dr Mr Mrs Ms Miss
• First name:
• Last name:
• Address:
• :
• Town:
• County:
• Postcode:
• Telephone:
• Email:If available.
• Neuromuscular Condition:
• Date of Birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
• Gender: Male Female

What do you require the grant for?

• Type of equipment:
• Details of equipment. Please give details of the item including model details and other specifications:
• What is the total cost of the equipment?:
• How much are you requesting?:

Equipment Assessment

• Name of the assessor:
• Qualification / occupation:

• Assessor's Employer:
• Assessors's Employer's Address:
• :
• Town:
• County:
• Postcode:
• Email:If available.

Fundraising

• Have you already sought other funding?: Yes No

• If yes, from who?:
• What was the the outcome (Or are you still waiting)?:

• How will you raise the balance?:

• In your own words how will this equipment be of benefit to the applicant? What difference will this equipment make?:

Applying for a wheelchair

• Are you applying for a wheelchair?: Yes No
  • What is the name / location of your NHS Wheelchair Service?:
  • Have you approached the NHS Wheelchair Service for an electric powered indoor/outdoor wheelchair or a manual lightweight wheelchair?: Yes No
    • If no, what is your reason for not approaching the NHS?:
    • Do you already have an NHS wheelchair? : Yes No
      • If yes, why do you need another wheelchair? Please give full details e.g. the added functions you require:
      • If you need a wheelchair and do not already have one, why do you not have a wheelchair? Please give full details e.g. waiting list – how long you have been waiting, have you been offered / are you in receipt of a wheelchair voucher?:

Further funding and publicity

• Funding from other sources

  From time to time the Joseph Patrick Trust, in partnership with other charities and organisations, is able to offer additional funding for the full cost of an item of equipment. Receiving an item of equipment might, however, involve attending an event to receive the equipment and local publicity and media coverage. Are you happy for us to consider you for this additional funding?: Yes No

• Telling your story – Can you help with our publicity?

  Personal stories about living with muscle disease create impact and bring news articles and features to life. Together with our Communications Ambassadors, we work constantly to raise awareness of muscle disease. Would you be willing to share your story?: Yes No

  We will not share your personal details with anyone else without your consent.

• Further Information

  In order to process your application we need to add your details to our secure database. Your details will be kept secure according to Data Protection Act and will not be shared with any third party. If you would like to receive our monthly e-newsletter, please tick here and supply your email address on the first page of this online form. If you do not wish to receive further information, please tick here.
  Are you eligible for any government means tested benefit?: Yes No Rather not say Please note this will not affect your application and is for statistical use only.

Terms & Conditions

The Joseph Patrick Trust provides a grant towards the cost of the purchase of equipment. Funding is provided on condition that the equipment is the property of the individual / family or a NHS Wheelchair Service, in partnership with the individual. In providing finance for the purchase of the equipment, the Joseph Patrick Trust does not take responsibility for the suitability or quality of the equipment or any liability for damage caused by the equipment or its use. When an individual has no further use for the equipment it is their responsibility to dispose of the equipment. When the equipment is a class 3 wheelchair, for the use by a young person under the age of 14 years, the speed setting must not be more than 4mph. When a grant is made fully funding such a wheelchair the parent/guardian of the young person will be sent a copy of the Highway Code, will be required to sign a statement agreeing to this stipulation and will be responsible for ensuring that the wheelchair supplier has set the limit to 4mph.

The Trust requires individuals to:

• Ensure the equipment is safe and appropriate
• Care for and maintain the equipment in good working order (carrying out necessary maintenance)
• Use the equipment safely and with due respect to others
• Insure the equipment appropriately

Joseph Patrick Trust will not provide grants for the following:

• Holidays, household adaptations or building works, domestic appliances.
• Equipment which has already been purchased.
• Recurring costs - Wheelchair repairs, insurance, batteries, tyres etc.
• Purchase or lease of vehicles; vehicle deposits; maintenance or repair of vehicles.

• I understand that I am responsible for ensuring that the equipment is appropriate for the applicant and operating safely.
• I agree to be responsible for ensuring that the equipment is used safely and correctly at all times.

Declaration

• Are you (or a member of your family) a Trustee of the Muscular Dystrophy Campaign?: Yes No
• Do you (or a member of your family) sit on any of the Muscular Dystrophy Campaign Committees?: Yes No
• If yes, please give details
• Name:
• Committee:
• I declare that the information I have given on this form is correct and complete, and I understand that information given will be held under the terms of the Data Protection Act.
• I agree that the Joseph Patrick Trust may request any information from the people or organisations given in this form, should it be considered necessary in order to deal with this application.

Consent

Consent is required from applicant, parent/guardian, if you are filling in this form on behalf of someone else.

• I give consent
• 
  OR
• I have obtained consent of applicant or parent/guardian
• Are you filling in this form on behalf of the person applying for help?: Yes No

• If yes, please give details

• Name:
• Address:
• :
• Town:
• County:
• Postcode:
• Email:If available.
• Telephone number (Day Time):
• What is your relationship to the applicant?:

Supporting documentation

Please don't forget to send us the following documents to arrive at least 10 days before the panel meets otherwise your application will not be considered. Please click here to view meeting dates.

• An assessment letter from a professional
• A quotation for the equipment (including an extended warranty)

Please send to:
Joseph Patrick Trust
Muscular Dystrophy Campaign
61 Southwark Street
London
SE1 0HL

Submit your application

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