• Details of person with MND
  • Details of requesting professional
  • Details of Equipment Loan Request
  • Funding by statutory agencies or others
  • Final details
  • Complete

The MND Association cannot use its resources to replace statutory responsibilities.  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 [email protected]

Title
If known.
Confirmation email will be sent to this address.

Contact details of a colleague who can be contacted if you are unavailable

Please note:  We are only able to loan iOS apps.  If the person has an Android or Windows device and you are applying for an app only, you need to complete an MND Support Care Grant application form to apply for funding towards the app.

If requesting an iPad, you need to state the AAC app that is required on the iPad. Please note that we will only provide one app:
Does the person currently have speech difficulties and require AAC to communicate?
Does the person have their own iPad/iPhone:

Please note: This section is mandatory. As a charity, we require details as to why statutory services/The NHS is unable to provide suitable AAC. Failure to complete this section fully may cause the application to be delayed. 

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.
  • I will ensure that loaned equipment is returned in a timely manner when it is no longer being used.
Please tick the boxes below to confirm you have read the statement above

The Association will follow procedures for recording, storing, and updating personal information all of which will comply with the Data Protection Act 1998 and any subsequent legislation including the General Data Protection Regulation.  We may occasionally share your information within the Association and with local health and social care professionals where it helps with your care and support or with development of better services.  If you have already expressed a preference for future contact we will follow these, if not, we may ask you for your views on how our services might be improved. If you do not want us to be in contact, please let us know on [email protected]

Please see our privacy policy for full details of how we use your information.  

In making this application I consent to:

  • This application being made for/on my behalf
  • Details of this application being held on record by the MND Association