Empower Fund application

We are committed to empowering the lives of our community by providing them the practical help they need now. We understand you beyond your condition and we want to invest in your dreams and ambitions.

By filling out this application form and submitting it to us, we’ll be able to assess your situation and need and hopefully send some money your way.

Please note that you must read the Guidelines to Applying for a Grant document before filling this form in - it has some pretty important info about the application process, what we will and won’t fund and other stuff to help you get your application right.

Any queries, please contact Emma or Sarah.

Once you have submitted your application we will call you to discuss any items we need clarification on. If your application is approved by our Empower Fund Grants Committee you will be notified in writing.

Please complete the form below

CONTACT DETAILS
Name *
Name
Date of Birth
Date of Birth
Are you an individual with a neuro muscular condition? If no, please specify the relationship you have to the person you are applying on behalf of and their details *
Name
Name
Date of Birth
Date of Birth
GRANT DETAILS
What type of grant are you applying for? *
$
Have you applied for an Empower Grant with us in the last 12 months? *
Have you applied for funding from other sources for this item? *
Have you received funding from another source for the same item you are applying for here *
HOUSEHOLD INCOME INFORMATION
Please include all sources of net income & pensions
$
$
$
HOUSEHOLD EXPENSES
$
$
$
$
$
$
$
$
DECLARATIONS
Grant Criteria *
True and Correct Declaration *
Information use acknowledged *