Full name (required)

Age (required)

Email address: (required)

Address:

Telephone: (required)

How much would you like to apply for? (£)

Please tell us how you / the applicant intends to use this gift:

Please describe the difference the above gift will make to the applicants life:

If your application is successful, Ali’s Gift will need to contact your Consultant to confirm your condition. Please confirm you grant Ali’s Gift permission to do so.
Yes (If the applicant is over 16 years old, they will need to grant this permission themselves. If they are under 16 years old they will need an parent or social worker to grant permission.)

CF Centre/Hospital attended (please include hospital address, email address and phone number):

CF consultant

Has the applicant ever received or registered for a gift/wish from another organisation?
YesNo

If yes, which organisation?

Who referred you to our organisation?

If your application is successful, would you be happy for us to share your story on our social media outlets in order to promote the good work that Ali’s Gift is doing?
YesNo

From time to time we send updates on the work we’ve been doing, gifts that have been given and events we’re holding. If you would like to receive these updates, please tick here Yes