Parent/Guardian Details Title (Mr/Mrs/Miss/Other) Full Name Email Address Phone Number Current Address Are you currently in paid employment? —Please choose an option—YesNo Job Title Job Industry Are you claiming means-tested welfare benefits such as Universal Credit? (Yes/No) —Please choose an option—YesNo Hospital and Child Details Name of Hospital Name of Ward Childs Full Name Childs Date of Birth Date of Admission Anticipated Length of Stay (days/weeks) Approximate Distance from Home to Hospital (miles) Number of Nights Accommodation Required How many adults will the accommodation be for? How many children will the accommodation be for? Start Date of Accommodation Do you have access to a car? —Please choose an option—YesNo Condition/diagnosis of the child (must be life threatening or life limiting): Additional Information and Special Requirements Please explain briefly why you are unable to fund accommodation costs yourself: Any Special Requirements for Accommodation Booking: Declaration I declare that the information I have provided is, to the best of my knowledge, correct. I understand the information provided will be used to process this application. I give permission for Evie's Gift to hold and process my personal data as part of the assessment process for assistance. I acknowledge that Evie's Gift will hold my details for 7 years to meet HMRC obligations. I agree to be contacted by Evie's Gift for feedback on their service. I agree to be contacted by Evie's Gift by email, post, and phone to keep up to date with latest news and fundraising activities. You have the right to withdraw consent at any time and request secure destruction of your information. View our privacy policy at www.eviesgift.org.uk. Further Information Have you applied to us before? —Please choose an option—YesNo Ethnicity Referral Partner Details Name of Referral Partner Name of Hospital or Organisation Job Title Referrer's Email Address Referrer's Contact Number I confirm that we, the referrer, will hold sensitive data relating to the applicant in compliance with GDPR.
