CAR-T Away from Home application form

Surname:

First name:

Title:

Email address:

Contact telephone number:

Home address:

Gender:

Date of birth:

Are you the patient or family member?
PatientFamily memberOther

If family member, please specify your relationship:

What type of support are you applying for? Cash grantHotel accommodationBoth

What is the patient’s diagnosis? Please be specific about the type of leukaemia they have.

Please provide the name and email of the consultant haematologist treating the patient. If you are being treated for your CAR-T in a different hospital to where you have previously received treatment, please tell us the contact details of the team who will give you CAR-T specifically.

Do you consent to us contacting your CAR-T care team (consultant and/or nurse) to discuss your CAR-T treatment and your application to our fund?
YesNo

Have you told the hospital that you have applied for this support?
YesNo

When do you expect the CAR-T treatment to start?

Share your story

This fund would not be possible without funding from our corporate partners. By submitting this form, you consent to us sharing the information in this form about why you need the grant anonymously through our own channels (e.g. internal reports, emails, social media) and with our corporate partners. We may also contact you to get more information about your situation. This will make sure we demonstrate the impact of the funding and is not optional. You will not be able to receive the grant if you object to this.

If you wish to share your wider experience without being anonymous, we would also welcome that. Telling the stories of people affected by leukaemia is vital to our work to support everyone affected by leukaemia in the future, including being able to show who is affected by leukaemia by sharing their names and pictures.

Please choose an option:
Please only share this information about me anonymouslyI would like to share my story more widely

Application agreement

I confirm I have read the terms and conditions and agree to abide by them. I also agree to provide written feedback once I have received the grant.

If you are applying for hotel accommodation, it is necessary to pass your details onto Dalata hotel groups to allow us to book the hotel on your behalf. By submitting the form, you consent to us doing this.

On submitting this form, you will automatically be enrolled in receiving our email communications about our services, campaigns, volunteer opportunities, and how to get involved.

Name:

Date: