Application Form – Wembley Compassionate Fund

For the use of the referring professional only

Before using this form, please read the guidance on our Referrals from Professionals page

Our application form requires your consent to our use of the information, so please read our data protection policy before completing this application by clicking on this link Privacy and Data Protection

You will receive a copy of the application by email and we will, in due course, notify the applicant that you have made this application on their behalf

**Fields marked * must be completed**

ALL INFORMATION PROVIDED WILL BE TREATED IN THE STRICTEST CONFIDENCE

Proposer's Name, Role and Address *

Proposer's telephone number *

Proposer's email address *

Confirm Email

Applicant's Name and Address *

Applicant's telephone number

Applicant's email address

Employment - describe the Applicant's current employment status, including the number of hours worked *

Applicant's income - itemise, describe and state the frequency and amounts of all sources of income to the household, including any benefits *

Applicant's outgoings - itemise, describe and state the frequency and amounts of all regular outgoings *

Applicant's debts - itemise, describe and state the amounts of all outstanding debts *

Family status - please indicate which of these best describes the Applicant's status *

Married or with a Partner
Single with some family support
Single with no family support
Other (comment in the box below)

Please comment if family status, above, is "other"

Children - give the ages of any children and state whether they are living with the Applicant

Outline the reasons why this application is being made, including the background to the Applicant's present circumstances and any health factors *

Specify what help is being sought, also stating, where relevant, whether assistance would be needed with installation or assembly *

GDPR consents - please confirm that you understand and accept our data protection policy and have informed and obtained the consent of the Applicant by checking the boxes below *

I have read the WCF data protection policy and I agree to my information being used by the WCF to contact me (by telephone, by email and in writing) and for keeping appropriate records.
I have informed the Applicant of the WCF data protection policy and have obtained the Applicant’s consent to the information in this application being used by WCF to make a decision on this application, to contact them (by telephone, by email and in writing) and for keeping appropriate records.