APPLY FOR FUNDING

We invite those who support or care for babies, children and adults with congenital heart disease in Yorkshire, the Humber and North Lincolnshire to apply to us for grants for projects that support our charity’s aim and mission.

CHSF encourages applications from all backgrounds, communities and departments. All applications will be considered impartially.

NOTE Please ensure you have read CHSF’s Grant Application Guidance before submitting an application for funding. Thank you.

There is a ‘Save & Continue’ function at the bottom of this form so you can save your application and come back later. Please be aware this will only save your application for 30 days and so we would strongly advise all applicants make a note of answers before filling in this form.

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Section A: Applicant Contact Details

Date of application(Required)

Day

Month

Year

Name:(Required)

Title First Last

Department / Organisation:(Required)

Position / Post / Job title:(Required)

Email:(Required)

Enter Email Confirm Email

Phone number:(Required)

Alternative phone number:(Required)

Address:(Required)

Street Address Address Line 2 City County Post code Country

Section B: Summary

Please provide a summary of your project including costs (maximum 50 words):(Required)

Section C: Application

1. Have you applied to Children's Heart Surgery Fund for funding before?(Required)

Yes

2. What are you requesting funding for?(Required)

If you are requesting funding for an upgraded model of equipment currently in use, please detail benefits of the improved model.

2b. If you are requesting funding for equipment or physical items, please upload an image:

Drop files here or

Max. file size: 50 MB.

3. Is this application a repeat funding request for a project previously supported by CHSF?(Required)

Yes

4. CHSF provide the funding and resources needed to care for a patient’s heart, mind, family and future. Which is the MAIN category that you would say this project falls into?(Required)

Heart

Mind

Family

Future

5. What is the need for this project or activity?(Required)

6. Who will benefit from this project or activity?(Required)

Please include the total number of people who will benefit and their ages and over what period

7. What is the timeline?(Required)

Please include dates of when your activity/project will start and finish. If you are requesting support for equipment, what is its lifespan?

8. What are the expected benefits/outcomes?(Required)

Please detail how this grant will make a difference to people with congenital heart disease, you, your patients, their families and the Leeds Congenital Heart Unit.

9. How will you measure your expected benefits/outcomes?(Required)

10. Please detail any plans to share these benefits/outcomes:(Required)

Section D: Costings

1. What is the total cost of your project/activity?(Required)

2. Please provide a full breakdown of the costs of your project/activity:(Required)

2b. Please attach copies of any quotes already received for the project/activity:

Drop files here or

Max. file size: 50 MB.

3a. Have you applied to your hospital's NHS Trust for funding for this activity/project?(Required)

Yes

3b. Why have you not applied to your hospital's NHS Trust for funding?(Required)

3b. What was the outcome of applying to your hospital's NHS Trust for funding? If you were turned down for funding what was the reason?(Required)

3c. Have you applied to your hospital's affiliated charity for funding for this activity/project?(Required)

Yes

3d. What was the outcome of applying to your hospital's affiliated charity for funding? If you were turned down for funding what was the reason?(Required)

3d. Why have you not applied to your hospital's affiliated charity for funding?(Required)

4. How much funding are you applying to Children's Heart Surgery Fund for?(Required)

4b. Is the above amount the full cost of the project/activity?(Required)

Yes

4c. You are not requesting the full amount from CHSF. How will the remainder be funded, and by whom?(Required)

5. Are there any ongoing costs for your project/activity?(Required)

Yes

5b. How will these ongoing costs be funded?(Required)

Please provide any further information you feel would support your application:

Upload additional supporting files/images:

Max. file size: 50 MB.

Section E: Terms of application

Necessary permissions(Required)

I have exercised due diligence and confirm that I have the required authorisation from all concerned stakeholders to apply for funding for this project, activity, equipment or resource. (This includes gaining permission from senior parties and ensuring equipment is compatible with current Trust infrastructure). I submit this application knowing that there are no obstacles to the ordering/implementation/undertaking of the agreed project at this time and any delays once funding has been agreed will be reported immediately to CHSF.

Please give the name and contact email of all stakeholders who have given authorisation for this project to proceed:(Required)

Use the (+) to add multiple contacts

Name

Email address

Photo and quote:(Required)

If successful, I agree to provide feedback pro-actively on my project/activity within six months (and in the case of events, up to one month after the event) as per the funding guidance.

Feedback consent:(Required)

I agree that if this application is successful, this feedback can be used by CHSF for marketing and publicity purposes and for inclusion in CHSF funding applications and the annual CHSF Social Impact Report.

Section F: Receiving funds

Should your application be successful, please specify your preferred method of receiving funding:(Required)

Submission of invoice (invoices to be made to Children’s Heart Surgery Fund)

Payment to UK bank account (Payment will be made on presentation of valid receipts)

Please provide details for the bank account in which funds will be paid if successful:(Required)

Please include the account number, bank sort code and name on the account

CAPTCHA

APPLY FOR FUNDING

*NOTE* Please ensure you have read CHSF’s Grant Application Guidance before submitting an application for funding. Thank you.

Section A: Applicant Contact Details

Section B: Summary

Section C: Application

Section D: Costings

Section E: Terms of application

Section F: Receiving funds

NOTE Please ensure you have read CHSF’s Grant Application Guidance before submitting an application for funding. Thank you.