Application – The Fluck Convalescent Fund

The Fluck Convalescent Fund

Application For Financial Grant

Details of Applicant

Details of Beneficiary

Reason for Application

Submit Request

Details of Applicant

First Name*

Last Name*

Organisation*

This is the Registered name of the Organisation. If the Organisation has not been Registered with the Fluck Fund please contact the Administrator by Please clicking here

Position in Organisation*

Phone Number*

Email Address*

Details of Beneficiary

First Name*

Last Name*

Address*

Area Code*

Post Code*

Reason for Application

Reason for Application (Circumstances of Beneficiary) *

Statement on Beneficiary’s State of Health*

Statement on Beneficiary’s Financial Situation (Detail Benefits etc)*

Purpose of Requested Grant and Amount.*

Amount*

To your knowledge has the potential beneficiary received a grant from the Fluck Convalescent Fund in the past?*

If YES please give details if known (This will not preclude a further grant but may affect the amount available)

I have applied to other Organisations for the purpose of this Grant*

If YES please list Names of other Organisations*

Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge. If this application leads to a grant award, I understand that I am agreeing to the terms and conditions set out below.

Signature*

Date*

Any other comments?

Terms and Conditions

Grants will only be awarded that meet the following criteria:
The Beneficiary:
1. Is female or a child, male or female, up to 18 years of age.
2. Is of poor financial means.
3. Is convalescing after illness, disease or surgical operation.
4. Is under the care of a Doctor or medical practitioner.
5. Lives within the City of Gloucester or its immediate surrounds (GL1, Parts of GL2, GL3 and GL4).
Any money awarded must be spent on the items/activity outlined in the application. Any monies remaining unspent must be returned to the Fluck Fund to be used for other grants.
To comply with Charity Commission rules, proof of expenditure will be required as soon as possible after the award of any grant.