Apply for a VICTA grant

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

Applicant details

First name *

Last name *

Gender *

Male
Female

Date of birth *

Age *

House number/name *

Street name *

Address line 2

City *

County *

Post code *

Contact phone number *

Alternative contact phone number

Email *

Confirm email *

Parent/guardian details (if applicant is over 8 but under 18)

Parent/guardian title

Parent/guardian first name

Parent/guardian surname

Parent/guardian home telephone number

Parent/guardian mobile/work telephone number

Parent/guardian home email

Further details

Name of eye condition? *

Is the applicant registered for this visual impairment? *

Yes
No

If yes, what date were they registered?

PLEASE NOTE

To qualify for a VICTA grant, applicants must be registered severely sight impaired, or be able to provide proof that they are registerable. Any information supplied must include the applicant’s name, date of birth and visual acuity. *

I confirm the applicant is registered or registerable as Severely Sight Impaired

Supporting documentation

If the applicant is registered, please include a copy of one of the following registration documents: - Certificate of Vision Impairment (CVI) - Blind Registration Card issued by local authority If the applicant is not registered, please provide: - a letter from an ophthalmologist confirming visual acuity. Please note, applications cannot be processed without these documents.

If you would like to upload any supporting documents such as a copy of your registration document, you can do so here. If supplying a CVI, please include Parts 1 & 2. If you are including a copy of a Blind Registration Card, please remember to include both sides. Only files saved as a jpeg or pdf formats will be accepted by the upload. Alternatively, you can email them to grants@victa.org.uk

Click or drag files to this area to upload. You can upload up to 5 files.

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.

Title

First name (supporter)

Last name (supporter)

Supporter profession/job title

Work telephone number (supporter)

Secondary contact number (supporter)

Supporter Email

Work address (supporter)

In what capacity do you know the applicant and for how long have you known 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 grants@victa.org.uk

Part 3 - Grant information

Item(s) requestion *

VICTA assigned laptop
Jaws Home Edition 2023
Dolphin Supernova Screen Reader 2023
Dolphin Supernova Screen Reader V22 USB
Dolphin Supernova Magnifier and Screen Reader V22 USB
ZoomText Magnification/Screen Reader 2023
Equipment to support independent living

Please provide further details of the equipment to support independent living you require *

Purpose of request (e.g. to enable the applicant to read books, cook independently) *

Does the applicant have experience of using this equipment? *

Please Note: if your application is successful you will be asked to make a financial contribution towards the purchase of the equipment. As a general rule, this will be 20% at the Trustees discretion. All past grant applications will be taken into account when making a decision.

Part 4 - Grant form completed by:

Title *

First name *

Surname *

Relationship to the applicant (if applicable)

Parent
Legal guardian
Support worker
Other

If other, please state

Part 5 - Declaration

Please select below which declaration you are required to sign *

You are over 18 and applying on your own behalf
You are completing as a Parent or Guardian of a child over 8 but under 18 years of age

By signing below you are confirming you have read, understand and agree to the declaration and consent Declaration I declare that the information provided on this form is complete and correct and enclose copies of the requested paperwork. I understand that this form is a request for a grant to be considered for approval by the Trustees of VICTA. Their decision is final. I understand that VICTA may discuss the information given on this form with other organisations who may be asked to provide relevant information, goods or services or to assist with the fulfilment of this grant. Consent In order for us to determine your eligibility for the VICTA grant under this application (which is either online or on a paper based form), we need to record sensitive personal data about you, including details of your health, which may also be defined as special category data ('Sensitive Data'). To comply with the law, we must tell you how we will use this Sensitive Data and ask for your permission to record it. By signing this consent form you are providing your permission for us to record your Sensitive Data for the purposes below. Use of your information Use of your Sensitive Data will only be used for the purpose of determining your eligibility for the VICTA grant, it will not be disclosed to any external or third party without your express written consent. Both electronic and paper records containing such data will be retained by VICTA for audit purposes.

Agreement to declaration *

Yes - I give my consent to VICTA recording Sensitive Data about me for the purpose of determining eligibility for a VICTA grant.
No - I do not give my consent to VICTA recording Sensitive Data about me for the purpose of determining eligibility for the VICTA grant.

Signed (insert name) *

Date *

Can I withhold or withdraw my consent? We will not record your Sensitive Data unless you provide your consent above. You are free to withdraw your consent at any time, by contacting VICTA at the address given below. We will not share your Sensitive Data with anyone else without your consent, unless required to do so by law.

By signing below you are confirming you have read, understand and agree to the declaration and consent Declaration I declare that the information provided on this form about my child is complete and correct and I enclose copies of the requested paperwork. I understand that this form is a request for a grant to be considered for approval by the Trustees of VICTA. Their decision is final. I understand that VICTA may discuss the information given on this form with other organisations who may be asked to provide relevant information, goods or services or to assist with the fulfilment of this grant. Consent In order for us to determine your child's* eligibility for the VICTA grant under this application, (which is either online or on a paper based form) we need to record sensitive personal data about your child, including details of their health, which may also be defined as special category data ('Sensitive Data'). To comply with the law, we must tell you how we will use this Sensitive Data and ask for your permission to record it. By signing this consent form you are providing your permission for us to record your child's Sensitive Data for the purposes below. Use of your child's information Use of your child's Sensitive Data will only be used for the purpose of determining their eligibility for the VICTA grant, it will not be disclosed to any external or third party without your express written consent. Both electronic and paper records containing such data will be retained by VICTA for audit purposes.

Consent (Parent/Guardian) *

Yes - I give my consent to VICTA recording Sensitive Data about my child for the purpose of determining eligibility for the VICTA grant.
No - I do not give my consent to VICTA recording Sensitive Data about my child for the purpose of determining eligibility for the VICTA grant.

Signed (parent/guardian) *

Date *

Can I withhold or withdraw my consent? We will not record your child's Sensitive Data unless you provide your consent above. You are free to withdraw your consent at any time, by contacting VICTA at the address given below. We will not share your child's Sensitive Data with anyone else without your consent, unless required to do so by law. * To include any child for which you have guardianship. Child to be defined as any individual under the age of 18.

Would you like to receive emails updates from VICTA regarding our activities and services? *

Yes
No
I'm already signed up

How did you hear about VICTA? *

Complaints handling procedure
VICTA Children Ltd has a complaints handling procedure. Full details of the complaints procedure are available on request by contacting us at: VICTA Children Ltd, Challenge House, Sherwood Drive, Milton Keynes MK3 6DP.

Apply for a VICTA grant

VICTA grant application form

Part 1 - About the applicant

Applicant details

Parent/guardian details (if applicant is over 8 but under 18)

Further details

Supporting documentation

Part 2 - Supporter details

Part 3 - Grant information

Part 4 - Grant form completed by:

Part 5 - Declaration

The application process

Step One – Application

Review

Step Two – Outcome

Confirmation

Step Three - Ordering

Delivery and feedback

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