What is your relationship to the child on whose behalf you are submitting this application?
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I am the child's Parent/Guardian (go to Section 2)
I am a Professional working with the child/family (go to Section 1a)
Email address
Have you discussed this grant application with the child's parent/guardian and gained their consent? (If no, please do so before continuing)
Yes
No
How long and in what capacity have you known this child?
Please confirm you have read and understood the Wellbeing Fund eligibility criteria and that in your professional judgement the child/family circumstances are compatible with them
I confirm compatibility with the Wellbeing Fund eligibility criteria
Name of Parent/Guardian 1
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First Name
Last Name
Relationship to Child (P/G 1)
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Phone number (P/G 1)
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Email address (P/G 1)
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Name of Parent/Guardian 2 (if applicable)
First Name
Last Name
Relationship to Child (P/G 2)
Phone number (P/G 2)
Email address (P/G 2)
Name of the Child
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First Name
Last Name
Date of birth
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MM
DD
YYYY
Gender
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Male
Female
Other
Religion
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No religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Any other religion
Address 1 - house name or number
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Address 2 - building name (if applicable)
Address 3 - street name
*
Address 4 - neighbourhood/area name (if applicable)
Address 5 - town/city/London borough name
*
Address 6 - county name
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Address 7 - post code
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Is this application being made on behalf of a looked after child?
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Yes
No
If a looked after child, please describe circumstances
Who lives at home with the child?
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Do any of the following family characteristics apply to this child? Tick all that apply
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Is the child a Young Carer? If no, specify 'Not a Young Carer' for all questions in this section.
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Yes
No
For whom does the child care? Tick all that apply
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Please describe the conditions of the person (or people) cared for by the child
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Which of the following caring tasks are undertaken by the child? Tick all that apply
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How do the child's caring responsibilities impact on them? Tick all that apply
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Is the child open to social care?
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Yes
No
If yes, please provide Social Worker name
If yes, please provide Social Worker contact number and/or email address
Is the child on the Child Protection register?
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Yes
No
If yes, please provide details
Does the child have a CAF?
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Yes
No
Unknown
Which other agencies are engaged with the child? Tick all that apply
*
If any engaged agencies are identified above, please specify the nature of their engagement and a contact name and number/email address
School Name
*
School Address
*
School Post Code
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Which of the following eligibility criteria apply to the child? Tick all that apply.
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If you have ticked A or B above, please confirm the family's agreement for Honeypot to approach the child's school for confirmation of eligibility. In the next question, specify the name and job title of the person we may contact for this purpose. This is NOT required IF you have also ticked G above.
I confirm Honeypot may approach the child's school to confirm eligibility
This application is sponsored by an appropriate professional
If applicable, please specify the name and job title of the person we may contact at the child's school
If you have ticked C - F above, please confirm that evidence in the form of a scan or photograph of a current statement of benefit(s) entitlement will be submitted to wellbeing@honeypot.org.uk alongside this application. This is NOT required IF you have also ticked G above.
I confirm evidence of current benefit entitlement will be submitted
This application is sponsored by an appropriate professional
Is the Professional Sponsor the same person as the Applicant?
Yes - go to section 9b
No - go to section 9a
Sponsor's name (if different from Applicant)
Sponsor's organisation name (employer)
Sponsor's job title
Sponsor's work email address
Sponsor's work phone number
I confirm the Professional Sponsor is aware and supportive of this application. I confirm they have given their consent to be contacted by Honeypot in order to validate their support. I confirm the family consents to the Professional Sponsor receiving a copy of this application for their review.
I confirm the sponsor is aware, supportive and willing to be contacted. I further confirm the family consents to the sponsor receiving a copy of this referral.
I confirm I have read and understood the role and expectations of the Professional Sponsor as stated in the Wellbeing Fund Objectives and Eligibility Criteria document
I confirm my agreement to the statement above
I confirm my professional support for the grant requested in this form
I confirm my agreement to the statement above
Please describe the purpose for which funding is sought. What product or service requires funding? Please provide as much detail as possible.
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What is the financial value (cost) of the requested product or service? If a precise value is not known, please estimate.
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What is the intended benefit of the product or service to the child? Tick all that apply
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Is there anything else you wish to tell Honeypot in support of this Wellbeing Grant application?
In submitting this grant application form you assert that all information contained herein is a true and accurate representation and that you have read and understood the Fund's Terms & Conditions. If you ARE the parent/guardian of the child on whose behalf this application is made, you confirm your consent to Honeypot sharing the application with other relevant parties as identified in this form for the purpose of validation of entitlement. If you ARE NOT the parent/guardian of the child on whose behalf this application is made, you assert that you are submitting this application with the parent/guardian's knowledge and explicit permission, and further that they explicitly consent to Honeypot sharing the application with other relevant parties as identified in this form for the purpose of validation of entitlement.
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I confirm my understanding of, and agreement with, the above statement
