Application Form - Let June Make a Difference

Child's name*

First Middle Last

Nationality

Ethnicity

Age*

Date of birth*

Address*

Street Town Postcode

School/College attended*

Do you consider the young person to have a disability?

Yes

If yes, what is the nature of the disability?

Does the young person qualify for pupil premium?*

Yes

No

Please complete this section if the young person you are applying on behalf of is not in receipt of pupil premium.

Income

Please provide a monthly total for each

Earnings

State Benefits

(Universal Credit, Attendance Allowance, Carer’s Allowance)

Other

(Incapacity Benefit, Child Benefit, Tax Credits)

Any other income

Hidden

Earnings

Hidden

State Benefits

(Universal Credit, Attendance Allowance, Carer’s Allowance)

Hidden

Other

(Incapacity Benefit, Child Benefit, Tax Credits)

Hidden

Any other income

Expenditure

Rent or mortgage

(deducting Housing Benefit)

Council Tax

Water rates

Gas & electricity

Other fuel costs

Building / contents insurance

Personal care

Any other significant expenditure

Hidden

Any other significant expenditure

Hidden

Personal care

Hidden

Building/contents insurance

Hidden

Other fuel costs

Hidden

Gas & electricity

Hidden

Water rates

Hidden

Council tax

Hidden

Rent or mortgage

(deducting Housing Benefit)

Please note that we do not require details of expenditure relating to housekeeping, telephone, travel and additional household expenditure. We take the national averages for these items from the figures issued in the Common Financial Statement, further details of which can be found via the Money Advice Service.

To build up a picture of the young person’s circumstances, please tell us how many people live in the household and their relationship to the child.

PLEASE DO NOT include the child in the numbers below:

Adults*

Children 0-14 yrs*

Children 14-18 yrs*

Hidden

Children 14-18yrs*

Hidden

Children 0-14yrs*

Hidden

Adults*

Relationship of the adult(s) to the young person (eg. parent, carer, grandparent):*

Organisation name*

Contact name*

Email*

Phone*

How do you know this child?*

Application date

What difference can we make?

Please tell us about the circumstances that have led to this application for a grant from Let June. What will the grant be used for and how will the grant improve the young person’s situation?

Specific expenditure

If the application is in respect of a particular item, please provide details of where this can be purchased together with details of its cost.

Additional information

If there is any further information you wish to share with us to support the application, please provide it here.

Data Protection

Let June respects your privacy and personal information. Details on how we use personal data can be found in our privacy policy on our website www.letjune.org/data Hard copies are available on request.

What happens now?

Please submit this completed application form using the button below.

We will acknowledge receipt of your application and let you know which of our Trustees will be managing the application.

Once we have all the relevant information, we aim to reach a decision within two weeks.

Declaration*

Please tick the box to confirm that the details provided in this form are correct

Keep in touch

If you would like to receive our email newsletter, please tick the box.

We will never share or sell your details to a third party and you can unsubscribe at any time.