Raise grant application form (full submission) Please enable JavaScript in your browser to complete this form.Thank you for confirming that your grant application meets our basic criteria. Please now proceed with your full application.Your NHS email address *Title *MrMrsMissMsDrProfOther (enter below)Title *Name *FirstLastYour mobile telephone number *Your direct dial NHS phone numberYour job title *Your department *Your hospital divisionWhat is the name of your manager? *In which of our hospitals are you based? *Please provide a short title for your application which clearly states what your grant is for *Please select the category or categories that apply to your grant *Patient experience (not including medical equipment)Patient medical equipmentPatient physical environmentDeveloping and supporting NHS Trust staffAre you applying for ... *a small grant (up to £4,999)?a medium grant (£5,000 to £24,999)?a large grant (£25,000 or more)?Move on to next sectionA. Please indicate the total cost of your project including funding from all other sources *B. Please indicate the total amount, if any, being funded from elsewhere, including from the NHS Trust *C. Please indicate the total grant you would like from Raise *Check your maths! Does A = B + C ?The amount entered is not compatible with the grant programme you are applying to. The small grant scheme funds up to £4,999. The medium grant scheme funds from £5,000 to £24,999. The large grant scheme funds £25,000 and above. Please amend your entries to be able to proceed.Please describe what you are proposing to use the money for. Ensure you provide a clear breakdown of costs if you are requesting multiple items. *You will be prompted to attach quotes at the end of this formIf this project includes maintenance or subscription costs or funding beyond that outlined in the grant application, please explain your plans for meeting the ongoing costs. *What difference will this grant make to patients and/or staff or West Hertfordshire Hospitals? Provide a brief explanation of the impact you expect the project to achieve. *Please explain how the item(s)/service(s) requested go above and beyond the minimum obligation of the NHS. Indicate how this is NOT integral and essential to the running of the NHS. The charity cannot fund things which are core NHS costs. *Explain how you will provide feedback to the charity about the impact of this grant. *Why do you believe Raise should prioritise funding your item(s)/service(s) over other requests? *Explain what makes this important and why it should be a priority for the charity, bearing in mind our commitment to patient and staff welfare.Please upload your NHS Trust approved business plan (applies to applications for £5,000 and above) * Click or drag files to this area to upload. You can upload up to 4 files. You can only upload PDF files, WORD documents, EXCEL spreadsheets, and photos (png/jpg/jpeg files)Please upload costings/quote(s). Applications must be supported by quotes and will not be processed until full costings are provided Click or drag files to this area to upload. You can upload up to 4 files. You can only upload PDF files, WORD documents, EXCEL spreadsheets, and photos (png/jpg/jpeg files)Go back to previous sectionMove on to final sectionYour declaration and grant submissionYou must be able to tick all of these checkboxes to be able to submit your grant application.All of the information provided, and any attachments, are true and complete to the best of my knowledgeI agree that the information in this form is being submitted to Raise for the purpose of grant funding applicationI am aware that my application will be stored on Raise's own web server; I have *not* disclosed any personal patient informationIf my application is successful, I agree thatRaise may publicise my project;I will provide feedback on the impact of the funding;I will acknowledge Raise as the funder in all communications about the project;I will provide appropriate reports as agreed;I will inform Raise immediately of any changes or amendments to the project;The project will commence within six months of notification of grant approval;The project will complete within twenty-four months or approval;The grant may be revoked or recalled if any of these terms are not metThank you for completing your application. Please check everything carefully and then submit your grant funding application by clicking the button below.Submit your grant aplication
