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Fundraise your way
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Find a fundraising event
Give in memory
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Leave a gift in your Will
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Pay in your fundraising money
Raffle
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Dysarthria
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Support and information
Our services
Equipment loan for MND
Equipment Loan request form
Equipment Loan request form
1
2
3
4
5
The MND Association cannot use its resources to replace statutory responsibilities. In completing this application form, health and social care professionals should include supporting documentation demonstrating efforts made to secure statutory provision. In signing this application form the professional confirms every effort has been made to seek statutory and other appropriate resources.
We will not process incomplete forms. Referring professionals must ensure applications are fully completed and returned in a timely manner. Please include ethnicity according to Department of Health coding.
If you have any queries about this application process, please email
support.services@mndassociation.org
1. Details of person with MND
Name
*
Full name of person with MND
consenting
to this request
Please select
Mr
Mrs
Miss
Ms
Dr
Prof
Rev
Title
First
Last
Date of birth:
*
DD
MM
YYYY
Address
*
Post Code
*
Postcode lookup only available for UK addresses
Find Address
Street Address
Address Line 2
City
Avon
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cleveland
Cornwall
Cumbria
Derbyshire
Devon
Dorset
Durham
East Sussex
Essex
Gloucestershire
Hampshire
Herefordshire
Hertfordshire
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
London
Merseyside
Middlesex
Norfolk
Northamptonshire
Northumberland
North Humberside
North Yorkshire
Nottinghamshire
Oxfordshire
Rutland
Shropshire
Somerset
South Humberside
South Yorkshire
Staffordshire
Suffolk
Surrey
Tyne and Wear
Warwickshire
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Clwyd
Dyfed
Gwent
Gwynedd
Mid Glamorgan
Powys
South Glamorgan
West Glamorgan
Aberdeenshire
Angus
Argyll
Ayrshire
Banffshire
Berwickshire
Bute
Caithness
Clackmannanshire
Dumfriesshire
Dunbartonshire
East Lothian
Fife
Inverness-shire
Kincardineshire
Kinross-shire
Kirkcudbrightshire
Lanarkshire
Midlothian
Moray
Nairnshire
Orkney
Peeblesshire
Perthshire
Renfrewshire
Ross-shire
Roxburghshire
Selkirkshire
Shetland
Stirlingshire
Sutherland
West Lothian
Wigtownshire
Antrim
Armagh
Down
Fermanagh
Londonderry
Tyrone
County
Postcode
Email
Telephone
Gender
*
Male
Female
Ethnicity code:
*
Please select:
A - British
B - Irish
C - Any other White background
D - White and Black Caribbean
E - White and Black African
F - White and Asian
G - Any other mixed background
H - Indian
J - Pakistani
K - Bangladeshi
L - Any other Asian background
M - Caribbean
N - African
P - Any other Black background
R - Chinese
S - Any other ethnic group
Z - Not stated
99 - Not known
Place of diagnosis:
(i.e. name of hospital/care centre)
Date of diagnosis:
*
2. Details of professionals
Name of requesting professional
*
First
Last
Job title
Address
Post Code
Postcode lookup only available for UK addresses
Find Address
Street Address
Address Line 2
City
Avon
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cleveland
Cornwall
Cumbria
Derbyshire
Devon
Dorset
Durham
East Sussex
Essex
Gloucestershire
Hampshire
Herefordshire
Hertfordshire
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
London
Merseyside
Middlesex
Norfolk
Northamptonshire
Northumberland
North Humberside
North Yorkshire
Nottinghamshire
Oxfordshire
Rutland
Shropshire
Somerset
South Humberside
South Yorkshire
Staffordshire
Suffolk
Surrey
Tyne and Wear
Warwickshire
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Clwyd
Dyfed
Gwent
Gwynedd
Mid Glamorgan
Powys
South Glamorgan
West Glamorgan
Aberdeenshire
Angus
Argyll
Ayrshire
Banffshire
Berwickshire
Bute
Caithness
Clackmannanshire
Dumfriesshire
Dunbartonshire
East Lothian
Fife
Inverness-shire
Kincardineshire
Kinross-shire
Kirkcudbrightshire
Lanarkshire
Midlothian
Moray
Nairnshire
Orkney
Peeblesshire
Perthshire
Renfrewshire
Ross-shire
Roxburghshire
Selkirkshire
Shetland
Stirlingshire
Sutherland
West Lothian
Wigtownshire
Antrim
Armagh
Down
Fermanagh
Londonderry
Tyrone
County
Postcode
Email
*
(Confirmation email will be sent to this address)
Telephone
Normal working hours when you can be contacted:
Contact details of a colleague who can be contacted if you are unavailable:
Name
First
Last
Telephone
Email
GP's Name
*
GP's address
Post Code
Postcode lookup only available for UK addresses
Find Address
Street Address
Address Line 2
City
Avon
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cleveland
Cornwall
Cumbria
Derbyshire
Devon
Dorset
Durham
East Sussex
Essex
Gloucestershire
Hampshire
Herefordshire
Hertfordshire
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
London
Merseyside
Middlesex
Norfolk
Northamptonshire
Northumberland
North Humberside
North Yorkshire
Nottinghamshire
Oxfordshire
Rutland
Shropshire
Somerset
South Humberside
South Yorkshire
Staffordshire
Suffolk
Surrey
Tyne and Wear
Warwickshire
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Clwyd
Dyfed
Gwent
Gwynedd
Mid Glamorgan
Powys
South Glamorgan
West Glamorgan
Aberdeenshire
Angus
Argyll
Ayrshire
Banffshire
Berwickshire
Bute
Caithness
Clackmannanshire
Dumfriesshire
Dunbartonshire
East Lothian
Fife
Inverness-shire
Kincardineshire
Kinross-shire
Kirkcudbrightshire
Lanarkshire
Midlothian
Moray
Nairnshire
Orkney
Peeblesshire
Perthshire
Renfrewshire
Ross-shire
Roxburghshire
Selkirkshire
Shetland
Stirlingshire
Sutherland
West Lothian
Wigtownshire
Antrim
Armagh
Down
Fermanagh
Londonderry
Tyrone
County
Postcode
3. Details of Equipment Loan Request
For all equipment requests, please provide a rationale for why you are applying.
For more information on how we loan apps, please see
this document
.
If the person with MND has already been referred to an AAC Specialist centre, please let us know.
Please note: The provision of suction units is a statutory requirement. While we are continuing to loan suction units, we are now requesting that statutory services contribute £50 towards the transport, maintenance and cleaning costs of each unit requested. Please tell us the name of the person we need to invoice for the £50 payment or send us a purchase order. This request should not delay delivery. We will continue to review the provision of suction units, along with other items that are part of our current core loan items.
For Suction units: Please tell us the name of the person we need to invoice for the £50 payment.
Items requested with details of specification:
Delivery address for equipment:
Post Code
Postcode lookup only available for UK addresses
Find Address
Street Address
Address Line 2
City
Avon
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cleveland
Cornwall
Cumbria
Derbyshire
Devon
Dorset
Durham
East Sussex
Essex
Gloucestershire
Hampshire
Herefordshire
Hertfordshire
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
London
Merseyside
Middlesex
Norfolk
Northamptonshire
Northumberland
North Humberside
North Yorkshire
Nottinghamshire
Oxfordshire
Rutland
Shropshire
Somerset
South Humberside
South Yorkshire
Staffordshire
Suffolk
Surrey
Tyne and Wear
Warwickshire
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Clwyd
Dyfed
Gwent
Gwynedd
Mid Glamorgan
Powys
South Glamorgan
West Glamorgan
Aberdeenshire
Angus
Argyll
Ayrshire
Banffshire
Berwickshire
Bute
Caithness
Clackmannanshire
Dumfriesshire
Dunbartonshire
East Lothian
Fife
Inverness-shire
Kincardineshire
Kinross-shire
Kirkcudbrightshire
Lanarkshire
Midlothian
Moray
Nairnshire
Orkney
Peeblesshire
Perthshire
Renfrewshire
Ross-shire
Roxburghshire
Selkirkshire
Shetland
Stirlingshire
Sutherland
West Lothian
Wigtownshire
Antrim
Armagh
Down
Fermanagh
Londonderry
Tyrone
County
Postcode
Telephone:
Any other relevant information:
4. Funding by statutory agencies or others
Please give detail of what attempts have been made to secure the equipment/funding from the statutory services:
Reason why this need cannot be met by statutory services. For all equipment requests, please provide a rationale for why you are applying:
If the equipment or service IS available from statutory services but there is a waiting list please state the date the equipment or service is likely to be available:
DD
MM
YYYY
Details of other charities or organisations that have been approached for funding. If the person with MND has already been referred to an AAC Specialist centre, please let us know:
5. Any other information relevant to the application
Please give details...
6. Statement by the referring professional
If this application is approved, I understand that, unless otherwise agreed with the support services team:
Where appropriate, it is my responsibility to continue to pursue funding from statutory services
It is my responsibility to monitor and assess the ongoing needs of the person with MND in relation to this application.
It is my responsibility to notify the relevant statutory service that the MND Association has provided equipment loan services to a person with MND
Should I leave my current post, I will notify the MND Association of the name of the professional who has taken on the responsibility for ongoing communication and liaison with the MND Association
I will monitor suitability, provide any necessary instruction, and will notify you when equipment is no longer needed.
Please tick the boxes below to confirm you have read the statement above
I agree to everything stated in the form above
I have read the MND Association
Privacy Policy
(Opens in a new window)
Date
*
DD
MM
YYYY
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