BENEFICIARY APPLICATION FORM

Application form for:

  • Cash Gift or Center Parcs Break
  • Memory Box or Sibling Box


Application forms must be sent via Mimecast, or password protected (encrypted) email to info@dragonflycancertrust.org

GLASS HEART APPLICATION FORM

Glass Hearts measure approximately 10 x 10cm, engraved with a handwritten message and delivered to the young person in a presentation box.

Glass Heart application forms may be sent as email attachments.

APPLICATION CRITERIA

  • The young person must be aged under 25 (0 – 24 years + 364 days)
  • The medical team must consider the young person’s cancer to be life threatening.

 

APPLICATIONS WILL BE ACCEPTED FROM:

  • The young person’s social worker
  • Directly from the family or young person if over the age of 16
  • Marie Curie Nurse / Macmillan Nurse
  • POONS team
  • Hospital Consultant or other relevant clinician (including Clinical Nurse Specialists)
  • GP or other senior health professional involved in the young person’s care

 

GUIDANCE NOTES:

  • All applications must be verified and signed by the referrer in the knowledge that the application is being made on behalf of the patient.

  • Please be aware that each application is assessed by the Board of Trustees and it is not guaranteed that every application will be successful. You are therefore advised not to promise/guarantee the young person or their family that the application will be successful.

  • The application must be made within a reasonable timeframe to enable DCT to respond appropriately and allow the recipient to use the gift in the way in which it was applied for.

  • Please be aware that by making this application you are required to provide confirmation that the medical team consider that the young person’s cancer to be life threatening.
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