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.
Grant Applicant Details
Applicants must be registered blind or partially sighted, or able to provide proof that they are registrable to qualify for a VICTA grant. Please upload your documents here in either pdf or jpeg format. Alternatively email them to email@example.com. Your application cannot be process until VICTA have received a copy of these documents.
Section 2 - Vacation Information
Part 3 - Finance
- If full funding is approved, you will be expected to contribute 10% of the total cost of the Activity Break.
- If only 50% funding is approved, you will be liable for the remaining amount, payable direct to Action for Blind People.
Part 4 - Grant form completed by
Part 5 - Declaration
- This section must be signed by the applicant if they are 18 and over or by the parent/guardian if under 18.
- I declare that the information provided on this form is complete and correct. 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 VICTA may discuss the information give on this form with other organisations who may be asked to provide relevant information, goods and services or assist with the grant.
- I agree that VICTA if required can request information related to this grant from other organisations.
- I have completed the required forms and enclose copies of the requested paperwork.
- 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 promise to inform VICTA of this so they can decide if the equipment should be passed on to another young person in need of such equipment.