HMHT Application Form

Applicant Details for Heworth Moor House Trust Grant

Applications are now closed
Applicant Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postcode
Phone Number*

Area CodePhone Number
Occupation Status (full time/part-time/unemployed)*
Family Details

Please include everyone who lives in the house. If extra boxes are required, please add any other members of the household in the additional information box below. To keep personal information to a minimum please do not include names of individuals other than the applicant unless specifically relevant.

Who are the other members of your family or household living with you?*

	Relationship to applicant	Date of Birth	Gender (where relevant)
1)
2)
3)
4)
5)
6)

Additional Applicant Information (eg. Other family members living in the applicant’s household, including relationship to the applicant)
Grant Details

Please give as much information as possible about the request, family need and describe how the grant would be beneficial. [Where possible leave out identifying information eg. instead of names, the term 'child 1' or 'child 2' etc is generally sufficient.]
Purpose of Grant*
Items required: Please include here the name of the proposed retailer, retailer's contact details, each item required, individual cost and item code if applicable. If applying for a grant for carpets please attach the proposed supplier's quote clearly identifying the room(s) to be carpeted and the individual cost of carpeting, underlay, fitting etc in the supporting documents box at the end of the form). *
To facilitate the process from grant application to receipt of goods it would help to check the current availability from the supplier (e.g. Argos) of the goods requested, using the Applicant's postcode for delivery.
If the specific item requested is unavailable do you agree to an alternative being supplied?*
Total amount of grant requested*
Normal maximum is £250
PLEASE NOTE: Heworth Moor House Trust requires cookers to be installed by the supplier. Grants for cookers are dependent on the suppliers' ability to install them
Payment Details

If this application is successful the payment or cheque will be made payable to Argos, an alternative retailer or the Sponsor's organisation. Please give details to whom the payment/cheque should be made and their address.

Argos orders: Argos will only process the order and make a delivery once they have made direct contact by phone with the applicant or the sponsor. Please let us know the preferred contact details for Argos. If this is not possible for any reason, please choose an alternative supplier at a comparable price.
Payment details and delivery contact details (telephone contact details required for retailer delivery)*
Have any requests been made to other charities to fund this/these items(s)? If so, please list these and any amounts offered or received.*
Sponsor's Details

This application can only be considered if it is supported and submitted by a professional worker or someone representing an organisation that the applicant is already in touch with. Please complete the section below.
Sponsor's name*

First NameLast Name
Organisation Name and Address*

Street Address

Street Address Line 2

CityState / Province

Postcode
Phone Number*

Area CodePhone Number
Email*
example@example.com
Data Privacy and Protection Policy

All sponsors and applicants completing a grant application or interacting with Heworth Moor House Trust need to be specifically aware that, through this activity with the Trust, you are accepting the need for the Trustees to collect (including via ‘cookies’), hold, use and share the information you have provided with third parties, as necessary, solely for the purpose of fulfilling our obligations in administration of the grant application in accordance with relevant data protection principles in Data Protection Act 1998 & General Data Protection Regulation 2018.

A copy of the Trust’s Data Privacy and Protection Policy can be obtained from the website: www.hmhtrust.org.uk/dataprivacyandprotectionpolicy.

The sponsor and applicant accept that personal information submitted to the Trust is used, as necessary, for administration of this grant application.
Supporting documents. Please attach relevant quotes or supplier or fitter information. Please note we cannot consider grants without the relevant information

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Applicant Details for Heworth Moor House Trust Grant

Family Details

Grant Details