Contact Us

Contact Us / Preliminary Application Form

If you think you are able to help us raise funds, or if you know a disabled youngster who needs our help, please fill in the application form below or email us at: [email protected].

Preliminary Application Form

* Indicates required field

Name of Child *

Email address (for us to contact you) *

D.O.B - Day *

D.O.B - Month *

D.O.B - Year (20XX) *

Family Address *

Postcode *

Family Telephone Number *

Does the child live with the family? *

Yes No

If "No" Please state the child's address *

Name and Address of child's school *

Postcode *

School's Telephone Number *

Please describe the nature of the child's disability *

Parent's surname, if different to child so that we can address letters correctly *

Submit

CHIPS Charity has only limited funds and therefore not all applications will be successful, CHIPS will only consider youngsters who have been unsuccessful with applications to local authorities, the NHS or Wheelchair Services. All applications are considered on their merits and grants made are dependant upon the availability of our funds at any particular time.
Regretfully we are unable to fund football/powerball wheelchairs.