Fields marked with a * are mandatory.
Note for applicants completing this form
After completion, if you have successfully submitted the form, you should receive a successful submission message. If you do not it may be because you have not completed a required field. Fields which have not been completed will then be marked with the message 'This is a required field' so you may wish to search this.
After your form has successfully gone through you will also receive notification via email. If you do not receive an email please contact the office on 01908 240 831 as there may have been a problem with your application.
Part 1 – About the applicant
1a. Applicant Details
Date of birth
Parent/guardian title (if the applicant is under 18 years)
Parent/guardian first name (if the applicant is under 18 years)
Parent/guardian Last name (if the applicant is under 18 years)
Address line 2
Contact phone number
Alternative contact phone number
Would you/the applicant describe yourself as blind or partially sighted?
Are you/the applicant registered for this visual impairment?
What date were you/the applicant registered?
Applicants must be registered blind or partially sighted, or able to provide proof that they are registrable to qualify for a VICTA grant.
Name of eye condition
Please list any other disabilities
1b. Current education/employment details
In this section, please complete the details of your/the applicant's current school/college/university/employer as applicable to you/the applicant. If you/the applicant are not currently in education or employment, please provide details for your most recent employer or educational provider with the date of leaving in the indicated box.
Name (educational provider/employer)
Date started Name (educational provider/employer)
Date of leaving educational provider/employment (if applicable)
Address (educational provider/employer)
Postcode (educational provider/employer)
Local LEA (if still in education)
Part 2 - Supporter Details
If you have a supporter e.g. a social worker or Qualified Teacher Visual Impairment (QTVI), please include their details here to support your application.
First name (supporter)
Last name (supporter)
Supporter profession/job title
Work telephone number (supporter)
Secondary contact number (supporter)
Work address (supporter)
In what capacity do you know the applicant and for how long have you know them?
Please provide a brief statement outlining the items required and why?
Please note, if you have any documents you would like to send to support the applicant's request further, they can be emailed to email@example.com
Part 3 - Grant Information
Item name (e.g. magnifying glass)
Purpose of request (e.g. to enable the applicant to read books)
Retail cost of item (e.g. £20)
Price quoted from (e.g. RNIB, if possible please provide a website link)
Does the applicant currently use this equipment at school?
If not, what experience does the applicant have of using the equipment?
Would you like to add a second item to this grant request?
Part 4 - Finance
If your application is successful, you will then be asked to make a financial contribution, at the trustees discretion, towards the purchase of your equipment.
How much would you like to contribute towards this equipment? (Please note this may differ from the final amount requested by the trustees)
Have you asked any other grant giving organisation for assistance with purchasing this item?
Have you already secured any funding toward the purchase of this item?
Have you applied to VICTA for a grant in the past?
Have you applied to any charities, trusts or organisation for a similar item in the past five years?
Are the family in receipt of benefits?
What is the annual household income?
Under £15,000 £15,001 to £20,000 £20,001 to £25,000 £25,001 to £30,000 £30,001 to £40,000 £40,001 to £50,000 £50,001 to £70,000 £70,001 +
Part 5 - Correspondence
How would you prefer to receive correspondence regarding your/the applicant's grant?
If applicable, please indicate your preferred reading format e.g. font size
How did you hear about VICTA?
Would you like to receive occasional emails from VICTA regarding our up-coming activities and services?
Part 6 - Grant Form Completed By
Full name (including title)
Relationship to the applicant (if applicable)
Part 7 - Declaration
This section must be agreed to by the applicant if they are 18 years or over, or by the parent/guardian if the applicant is under 18 years of age.
I declare that the information provided on this form is complete and correct and I undertake to update VICTA should any of the information in this form change.
I understand that information given will be held under the terms of the Data Protection Act.
I agree that VICTA can use the information I have supplied on this form, including details about my sight condition, in order to deal with my grant application and provide me with information of other support services. I agree that VICTA may discuss the information given on this form with other organisations who may be asked to provide relevant information, goods and services to assist with this grant.
I agree to provide copies of the required supporting documents to VICTA. This will include copies of registration documents or proof that the applicant is registrable. Documents can be sent by email to firstname.lastname@example.org or by post to VICTA Children Ltd, 5 Douglas House, 32-34 Simpson Road, Fenny Stratford, Milton Keynes MK1 1BA.
I understand that this form is a request for a grant to be considered by the Trustees of VICTA and that the Trustees decision is final.
I understand that if funding is approved VICTA is not required to provide payment towards the upkeep of this equipment, including replacement, maintenance, insurance, extended warranties etc. Any such undertaking shall be the responsibility of the beneficiary, parent, legal guardian or other.
I agree that if funding is approved and at a later date the recipient no longer requires this equipment, I/the recipient will endeavour to inform VICTA so they can decide if the equipment should be passed on to another young person who may benefit from it.
I consent to have any photographs/thank you letters that I send to the charity used for publicity purposes, including online and in printed documents.
Agreement to declaration
Signed (insert name)
Relationship to the applicant (if applicable)
If you would like to upload any supporting documents such as a copy of your registration documents you can do so here. If supplying a CVI please include parts 1 and 2. If you are sending a copy of a card, please make sure you include both sides. The information must include the applicants name, date of birth and visual acuity. Only files saved as jpeg or pdf formats will be accepted by the upload. Alternatively you can email them to email@example.com