Funding for Individuals Referral Form

SECTION 1 - Referring Organisation Details
Referee name *
Referee name
Address, including postcode *
Address, including postcode
SECTION 2 - Applicant’s Details
Current address, including postcode *
Current address, including postcode
Health & disability
Are there any concerns regarding lone working?
SECTION 3 – Support Required
Please tick & then complete relevant section (i.e. section 3A)
Household Funding
Transport Funding
Funding for Children & Young People
Vocational Funding
SECTION 3A – White Goods & Utilities Arrears
SECTION 3B – Transport & Childcare
SECTION 3C – School Holiday Club & Extra Curricular Activities
SECTION 3D – School Trip
SECTION 3E - Course Fees & Accreditation
Type of study
SECTION 3F – Course Kit, Uniform & Materials
SECTION 4 – Statement & Other Support


Amina Lawson
0203 328 0246 or 01932 220242

Walton Charity
Charities House
2 The Quintet
Churchfield Road
Walton on Thames
Surrey, KT12 2TZ

Please be aware we will call from the above numbers, which start with ‘0203’

DATA PROTECTION: By signing this form the applicant agrees to the information on the form being stored in Walton-on-Thames Charity manual filing system and summarized on the computer for the sole purpose of grant processing, analysis and accounting. All information will be treated in the strictest confidence and will not be divulged without the prior agreement of those concerned.