Small Grant Reimbursement Pre-Approval £1,000 or More

Page 1

Applicant Details

Title

First Name

Surname

Job Title

Department, Ward or Area

Care Group

KCH Site where you are primarily based

Please provide the name of the site you are applying from

Organisation

Please provide the name of the organisation you are applying from

Work Phone

Work Email

Page 2

Reimbursement pre-approval details

Grant Title

Designated Fund Name

Designated Fund Number

Amount

Grant Description

Please provide a description of the reimbursement pre-approval being requested and the reasoning behind the spend?

How will the request benefit patients, families, staff or other service users of King's?

Explain how this meets the Charity's grant expenditure principles that an item should be over and above what is required for an NHS service

Page 3

Applicant Declaration

I confirm that the expenditure detailed on this form conforms to the Charity’s expenditure principles, is for the purpose detailed in this application and is consistent with the purpose for which the fund was set up.
I have obtained all the required FT approvals and confirm that no other sources of funds are available to fund this expenditure.

I confirm the above statement

I have read and understood the Charity’s Data Privacy Statement regarding use of the above personal data and confirm I agree to this use of personal data.

I confirm the above statement

Date

IMPORTANT: In the next screen you will be able to save a PDF copy of your application by clicking Print this page and from the Destination drop down select Save as PDF.