Dementia Support Fund

In Memory of Lesley Connor

Dementia Support Funding Application

Patient's First Name

Patient's Last Name

Contact Address

Contact Email

Contact Phone Number

Your Details (if applying on behalf of Patient)

Please give a brief description of the Patient's medical diagnosis, (ONLY THE FIRST 300 WORDS WILL BE ACCEPTED

Please give a brief description of your financial support needs and how this fund will assist (ONLY THE FIRST 300 WORDS WILL BE ACCEPTED)

Please provide the following supporting information:

Please give a brief description of your current support team (If any) This can include GP, Social Workers, Specialist Dementia teams. (ONLY THE FIRST 300 WORDS WILL BE ACCEPTED)

Photo ID for yourself (Applicant)

Upload File

Upload supported file (Max 15MB)

Evidence of Dementia Diagnosis

Upload File

Upload supported file (Max 15MB)

Any other relevant supporting documents

Upload File

Upload supported file (Max 15MB)

Please do not submit the application without the supporting information as we cannot accept it.
If you have any problems with providing any of the information, please contact us to discuss before submitting your application.

This grant application will be assessed by a team at The PFC Trust with specialist Guidance provided by experts within this field

Agreement

By signing this agreement, you confirm that you, and your organisation, agree to all the
terms, principles and application process as detailed in the PFC Trust Grant Making
Policy

Your Signature

You are requested not to share any information contained on this form without consent of THE PFC Trust, Thank you.

Thanks for submitting!