SSIT

Donations in memory of Horatio Chapple will fund an accessible garden at the Duke of Cornwall Spinal Treatment Centre.

Donations in memory of Horatio Chapple

People with spinal cord injury are encouraged to apply to SSIT for help with the provision of equipment needed to promote independence and good health.

Donate online

Please help us continue our work providing equipment and facilities for the Duke of Cornwall Spinal Treatment Centre and assisting people with spinal cord injury living in the region.

Bloomsbury Art Fair raising funds for SSIT

SSIT provides grants to spinally injured people to assist with the funding of specialist equipment, enabling greater independence and participation in society again.

Click here to download this form as a blank PDF for you to complete by hand.

Please complete the following form, all items marked with * are required.

Personal information

Title:
Surname:
Forename:
Initals:
Address:
Postcode:
Telephone:
Mobile:
Email:	(E-mail)
Date of Birth:	(DD/MM/YYYY)
Date of Injury:	(DD/MM/YYYY)
Injury Level:

Equipment request information

Details of the item you are requesting funding for:
Cost (inc V.A.T.):	£

Have you applied for funding elsewhere?

SSIT expects the applicant to have investigated all other sources of funding and can only pay for equipment that cannot be obtained in any other way.
	Please indicate contribution (if known) in box provided.
NHS wheelchair services:	£
Social Services:	£
Local Health Authority:	£
Motability:	£
Other Charity or Trust:	£

If you are applying for a wheelchair you must approach your local NHS wheelchair services first. If they cannot help with your application please attach their rejection letter. Your application cannot be considered without this.

Can you make a contribution towards the cost of this equipment?

Yes?:
If 'Yes' how much?:	£

Physiotherapist or Occupational Therapist Details

If your application relates to a mechanical item (eg. wheelchairs, wheelchair accessories, e-motion wheels, exercise equipment, profiling beds etc), you will need the supporting signature from your Physiotherapist or Occupational Therapist to say that they have assessed you using the equipment and that in their opinion it is suitable and safe.
OT/Physio?*:
Name:
Address:
Telephone:

Consultant, GP, Occupational Therapist, Physiotherapist, Social Worker or Care Manager Details

If your application is not for a mechanical item, please ensure that your Consultant, GP, Occupational Therapist, Physiotherapist, Social Services or Care Manager supports your application.
Name:
Job Title:
Address:
Telephone:

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