APPLICATION | Victoria Hospital

Assistance Request Form

Grant application for medical or medically related expenses.

By completing and submitting this form, you confirm that this information is accurate and agree that Victoria Hospital Incorporated can use the details provided to process your grant application, including any sensitive information such as details about your health.

You may complete the application on behalf of someone else only if they have given you explicit permission to do so.

You can find out more about how we will use your information in our privacy statement which can be found online.

Email admin@vhi.org.gg

First Name

Last Name

Date of Birth

Address

Post Code

Telephone

Occupation

Spouse or Partner

First Name

Last Name

Date of Birth

Occupation

Dependants

Full Name

Date of Birth

Full Name

Date of Birth

Full Name

Date of Birth

Application Details

What amount are you applying for? If it is for a grant for equipment, then please give an estimate. Note that if it includes doctor’s bills, we are not usually able to consider any over two years old.

Please give brief details of why you are applying for this grant including any relevant medical needs

Please include a summary of any accident, illness or other change of circumstances that may have significantly affected your household financial situation

Have you applied to Social Security for help with your medical expenses? If you have been refused, what was the reason given?

Have you asked for assistance with this claim elsewhere? Please give details

Financial Details

Earnings

Pension(s)

Child maintenance received

Other benefits (specify below)

Income Support

Other benefits (specify below)

Long answer

Household Expenditure

Weekly

Monthly

Rent or mortgage including TRP and parish rates

Maintenance payments

Food and housekeeping

Services (Power/telephone/transport etc.)

Sundries (Clothes, household goods, etc.), on average

Healthcare costs (GP visits, prescriptions etc.)

Loan repayments

Do you have any outstanding debts? If so, please give brief details.

It may help us help to process this application more quickly if we can contact the following:

Please tick the box if you do NOT agree

Social Security

Only tick this box if you do NOT want us to contact social security.

Medical or other professional(s).

Only tick this box if you do NOT want us to contact medical or other professional(s).

Contact details of medical or other professional(s)

Full Name

Telephone /Email

Signature - claimant or person nominated below

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If completed on behalf of the claimant

I certify that the claimant has agreed to me submitting this claim for them and that the information provided is an accurate and complete record of that provided to me by them or is otherwise within my knowledge.

Full Name

Telephone

Profession and organisation

Date

Where did you hear about VHI?