Cost of Living Fund – Application form

Who is submitting this form? e.g. a patient or a family member on behalf of the patient

PatientCaseworkerCharity workerFamily member, friend or carer

Please tell us your first and surname (if you are not the patient):

Please provide an email address:

Please provide a telephone number:

Details of the patient receiving the fund

Title:

First name:

Surname:

Patient date of birth:

Email address:

Contact telephone number:

Home address:

Gender:

What is the patient’s diagnosis?

What hospital is the patient being treated at? Please provide the name and email of the consultant haematologist treating the patient.

What will the patient use the grant for?
Car repairs/maintenanceCost of foodDay tripsEnergy billsHospital travelReduced incomeWhite goods and furnitureOther
If other, please state:

Please upload a copy of the patient's diagnosis letter (please provide any letter from your hospital that states your diagnosis)

Share your story

If you wish to share your story of diagnosis or supporting someone with a blood cancer, please let us know and we will get in touch with you. We use stories to show our impact to supporters but also in campaigning work to improve the lives of people affected by blood cancer.

I would like to share my story

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.

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. You can unsubscribe at any time by calling 01905 755977 or by emailing communications@leukaemiacare.org.uk. We will never swap your details with other organisations or share them with other charities for marketing purposes.

Name:

Date: