Please ensure you have scanned or clear photos of your evidence needed to proceed with your application. By clicking the following link, a pop up window will appear. To close the window, click on the X in the top right corner and you will return to this page. Please click here to see a list of evidence needed.
If somebody applies on your behalf they should include a letter of endorsement from an approved authority. By clicking the following link, a pop up window will appear. To close the window, click on the X in the top right corner and you will return to this page. Please click here to see a list of approved authorities.
Note that this application form cannot be saved and if you close the window, any information added will be lost and you will have to start the application process from the start.
EVIDENCE REQUIREMENTS
- A recent payslip or employment contract if applicable. We use this for evidence of your salary and confirmation that you work or have worked in the community.
- Copies of certificates of training and development courses relevant to community practice.
- At least two written quotes or estimates if you are requesting assistance for a specific item or service.
ABOUT YOUR NURSING CAREER
DECLARATION OF YOUR WEEKLY/MONTHLY INCOME & EXPENDITURE
START APPLICATION
Are you a Registered Nurse who is, or have been employed for example as a district nurse, health visitor, school nurse, community specialist nurse, community psychiatric nurse, learning disability nurse, or a community midwife and hold a bank account solely in your own name?
Unfortunately we are unable to help you. Please visit our Links page to view a list of other organisations that may be able to help.
PERSONAL DETAILS OF NURSE
Title
First Name
Last Name
Maiden Name
NMC/UKCC or GNC No
DOB
Full Home Address Including Postcode
Preferred Telephone (with no space)
Email Address
THIRD PARTY APPLICANT
Are you making this application on behalf of the Registered Nurse?
No action needed – please proceed to the next step.
Full Name
Address Including Postcode
Relationship to nurse: if you are a relation please send a scan or photo of a letter confirming your relationship signed by a suitable authority.
You should include a letter of endorsement from an approved authority.
Upload your letter
Max. size: 10.0 MB
TRAINING HISTORY
Name of your nurse training school/college/university, Dates and Qualifications
Name of community nursing education college/university, Dates and Qualifications
COMMUNITY NURSING EMPLOYMENT HISTORY ONLY
Name of Community Nursing Authority, Dates and Post Held/Job Title
ABOUT YOUR PRESENT OR PREVIOUS EMPLOYMENT AND/OR RETIREMENT
Are you currently in employment?
Please state reason
Are you currently retired?
What date did you retire?
Were you retired on health grounds?
HOUSING STATUS
Do you live alone or share accommodation?
DETAILS OF DEPENDENTS
Do you have any dependents?
Name
Age
Relationship
Living at Home?
Do you want to add another dependent?
Name
Age
Relationship
Living at Home?
Do you want to add another dependent?
Name
Age
Relationship
Living at Home?
Do you want to add another dependent?
Name
Age
Relationship
Living at Home?
Do you want to add another dependent?
Name
Age
Relationship
Living at Home?
Do you want to add another dependent?
Name
Age
Relationship
Living at Home?
Please add any additional dependents in the Extra Notes section at the end of the application form.
Do you have savings in any of the following? Please state amounts (£’s only)
Current Bank Account
Deposit Bank Account
Building Society Accounts
Post Office Account
Stocks and Shares
Tessa’s and ISA’s
Other Assets
Please advise us of the details of your bank account for use if you are awarded a grant; this needs to be a single account held in your name
Name of Bank
Account Name
Sort Code
Account Number
INCOME
Salary
Salary Frequency
Statutory Sick Pay (Per Week/Month)
State Retirement Pension (Per Week/Month)
Child Benefit (Per Week/Month)
Family Credit (Per Week/Month)
Housing Benefit (Per Week/Month)
DSS Benefit/Universal Credit (Per Week/Month)
Council Tax Rebate (Per Week/Month)
NHS Pension (Per Week/Month)
Occupational Pension (Per Week/Month)
Regular Income from Charitable Funds (Per Week/Month)
Income of Spouse/Partner (Per Week/Month)
Income from Lodgers (Per Week/Month)
Income from Family (Per Week/Month)
Other (Per Week/Month)
EXPENDITURE
Please only list debts and loans which you are solely responsible for.
Mortgage/Rent (Per Week/Month)
Council Tax (Per Week/Month)
Water Rates (Per Week/Month)
Gas (Per Week/Month)
Electric (Per Week/Month)
Telephone (Per Week/Month)
Television (Per Week/Month)
Food (Per Week/Month)
Clothing & Necessities (Per Week/Month)
Insurance (Per Week/Month)
Travel/Car Expenses (Per Week/Month)
Debt Repayments (Per Week/Month)
Loan Repayments (Per Week/Month)
Other (Per Week/Month)
REASON FOR APPLICATION
Why do you think you may be eligible for consideration of a grant from the 1930 Fund? Include details of your need.
FINAL STEP
Amount of funding requested (£)
How did you hear about the 1930 Fund For District Nurses?
Have you applied before?
Date of Grant Received
Amount's Received (£)
Are you currently applying or have you applied to any other charitable trust in the last 3 years?
Name of Trust
Date Applied
Amount Requested (£)
Amount Received (£)
WOULD YOU LIKE TO ADD ANOTHER?
Name of Trust
Date Appled
Amount Requested (£)
Amount Received (£)
WOULD YOU LIKE TO ADD ANOTHER?
Name of Trust
Date Applied
Amount Requested (£)
Amount Received (£)
If you need to add more, please put them in the Extra Notes section at the end of the application form.
Would any of your existing benefits be affected by this grant?
Please explain how and why
EVIDENCE REQUIRED
Please provide the following information:
1. A recent payslip, if applicable.
2. Copies of certificates of training and development courses relevant to Community practice.
3. At least two quotes if work is being undertaken and services provided.
Please note that you can select multiple files to upload.
Upload Evidence
Max. size: 10.0 MB
Upload Evidence
Max. size: 10.0 MB
Upload Evidence
Max. size: 10.0 MB
Upload Evidence
Max. size: 10.0 MB
Extra Notes
Declaration
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