CAR-T Away from Home application form

To apply for our CAR-T away from home service please complete the below application form and a member of the team will be in touch.

All the below questions are required. If you require any further information please email

    Share your story

    This fund would not be possible without funding from our corporate partners. By submitting this form, you consent to us sharing the information in this form about why you need the grant anonymously through our own channels (e.g. internal reports, emails, social media) and with our corporate partners. We may also contact you to get more information about your situation. This will make sure we demonstrate the impact of the funding and is not optional. You will not be able to receive the grant if you object to this.

    If you wish to share your wider experience without being anonymous, we would also welcome that. Telling the stories of people affected by leukaemia is vital to our work to support everyone affected by leukaemia in the future, including being able to show who is affected by leukaemia by sharing their names and pictures.

    Please choose an option:

    Application agreement

    I confirm I have read the terms and conditions and agree to abide by them. I also agree to provide written feedback once I have received the grant.

    If you are applying for hotel accommodation, it is necessary to pass your details onto Dalata hotel groups to allow us to book the hotel on your behalf. By submitting the form, you consent to us doing this.

    On submitting this form, you will automatically be enrolled in receiving our email communications about our services, campaigns, volunteer opportunities, and how to get involved.