Grant Assistance Scheme

THIS FORM MUST ONLY BE COMPLETED IF YOU HAVE BEEN INSTRUCTED TO DO SO BY OUR MEMBER OF THE AYL TEAM.

ONCE COMPLETED, YOU WILL BE ASKED TO PAY FOR YOUR PREFERRED SUPPORT PACKAGE (MORE DETAILS BELOW). PROVIDING YOU WITH INSTANT ACCESS TO OUR MOST TRUSTED SUPPLIERS WHO HAVE KINDLY OFFERED TO DEDUCT THE COST OF THIS SERVICE FROM YOUR FINAL PRODUCT BILL. ESSENTIALLY ALLOWING YOU TO UTILISE THIS SCHEME FREE OF CHARGE!

FOR NEW USERS, PLEASE START YOUR EQUIPMENT JOURNEY BY FILLING OUT OUR REQUEST FORM.

Grant Assistance Form

Personal Information:

Full Name:
*

Date Of Birth:
*

Email:
*

Medical Information:

Have Previously Applied For / Received Any Disability Related Grants?

Do You Currently Receive Any Benefits?
*

Employment and Support Allowance (ESA)

Personal Independence Payment (PIP)

Disability Living Allowance (DLA)

Attendance Allowance

Universal Credit

Appealing / Processing Application

No Benefits Received

OtherOther

(You Can Select More Than One Option)

Payment Preferences:

Please Select Your Chosen Payment Package:
*

Tier 1 = £50 (Aims To Raise Up To £1000 With 2 Hours Of Support)

Tier 2 = £100 (Aims To Raise Up To £2500 With 4 Hours Of Support)

Tier 3 = £150 (Aims To Raise Over £2500 With 6 Hours Of Support)

(All Tiers Aim To Raise Funds Through Grant Applications And/Or Crowdfunding)

Please Select Your Preferred Payment Method:
*

Bank Transfer

PayPal Invoice

Terms & Conditions:

Staying Connected:

I Would Like To Receive Regular Updates, Offers & Information.

Confirmation:
*

I Understand The Above Questions Will Help Access Your Life Source Grants & Write Applications.

I Understand Access Your Life Cannot Guarantee I Will Receive Financial Support.

I Understand I Will Need To Discuss Financial Information To Apply For Funding.

I Understand I Will Need To Source A Supporting Letter From An Physio/Occupational Therapist To Apply For Funding.

I Understand That Access Your Life Can Facilitate A Private Supporting Letter For An Additional Cost If Needed.

I Understand That If My Yearly Household Income Is Over £35,000, I Will Receive More Fundraising Based Support.

GDPR Privacy:
*

I Have Read & Understood Access Your Life's Privacy Policy & Terms of Use.

Captcha:

NEED HELP SUBMITTING THIS FORM?

IF YOU REQUIRE ASSISTANCE COMPLETING THIS FORMS, PLEASE CALL:
07594650130

LEAVE A MESSAGE WITH YOUR NAME AND NUMBER & OUR CASE MANAGER WILL GET BACK TO YOU AS SOON AS POSSIBLE.
(USUALLY BETWEEN 10AM AND 4PM GMT, MONDAY TO FRIDAY)

YOU CAN ALSO EMAIL ANY QUESTIONS TO:
[email protected]

Personal Information:

Medical Information:

Payment Preferences:

Terms & Conditions:

NEED HELP SUBMITTING THIS FORM?

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