FOR OFFICE USE ONLY

REFERENCE NUMBER: .......................................

Acknowledged email/letter: ..............................

Decision: £..............................................

Informed email/letter: ..................................

Pain Trust Individual Application Form

This form is to be used for one individual only - if you are a group of friends, or a constituted group, please contact us for a different form.

Either complete the online form below and press submit or print the page and post it to:
The Pain Trust, 15 Rolle Street, Exmouth, Devon EX8 1HA

Personal Details
Name:
Address:
Telephone Number
E-Mail Address: *This will be used for future communications
Date of Birth: * please enter a DD/MM/YYYY

Education/Employment
Are you currently:
In full time education	at school at college
In part time education	at school at college
In full time employment
In part time employment
Will your education/working status change between now and the start of your adventure?

Proposed Adventure
Destination:
Start date: * please enter a DD/MM/YYYY
Finish date: * please enter a DD/MM/YYYY
Date funding required by: * please enter a DD/MM/YYYY
How many people will be taking part in your adventure?
if your adventure is being organised by a group (e.g. your school), please give the following details:
Name of Leader
Contact Address
Contact telephone number

Safety Considerations
Name of organisation (or holiday company) providing activity (if any).
Activity centre licence Number (if applicable)
Are the supervising staff qualified?	Yes No Don't know
Do you have insurance cover for the activity? (please enclose details of insurance cover)	Yes No Included in package Details of Insurance
Are you undertaking any training for this adventure? (please give details)

Cost of Adventure
What is the total cost of your adventure?
In addition to this application, what steps are you taking to secure funding for your adventure?
Other Charities:
Name	Amount received



Fundraising:
Event	Amount received
Personal/Parental contribution


if the Pain Trust declines to support your application, will you still go ahead with your plans:	Yes No

Previous Contact
If you have previously received a Pain Trust gran (group or individual), please give details:
Alternatively, if this is your first application - how did you hear about the Trust?

About Your Adventure
Component of Adventure	Breakdown of Costs
TRAVEL
ACCOMMODATION
FOOD ETC
PROFESSIONAL INSTRUCTION
OTHER COSTS:
Insurance
Activities
TOTAL COST

Where are you going, and what are you doing?
Please provide a detailed itinerary of your proposed adventure.
Date - please specify in format dd/mm/yyyy	Activity










Please write a letter below, outlining why you feel the Pain Trust should support your application:

I confirm that the details provided on this application form are accurate and correct at the time of writing.
Name/Signature:	Date:

If the applicant is under 18 [Parent/Guardian's Consent] I approve of the above named making an application for assistance and of his undertaking this adventure. i understand that the Trustees accept no responsibility whatsoever for any aspect of this venture and I further understand that should a grant be made and this venture not proceed as detailed I will inform the Pain Trust accordingly and undertake to refund the grant in whole or in part as may be required.
Name/Signature:	Date: