Charity Grant Request Form

Grants made by Valley Hospital Charity are for the benefit of patients and staff at Dartford and Gravesham NHS Trust. These can be projects or equipment on the sites of Darent Valley Hospital or Queen Mary’s at Sidcup where the Trust operates, or to benefit our remote staff and patients providing care in the community.

Grants can only be applied for by members of Dartford & Gravesham NHS Trust staff and with prior approval by a line manager.

Capital item requests over £5,000 will need to be additionally approved at the Capital Investment Committee to ensure there are no revenue implications and that equipment is in line with Trust priorities.

For guidance on what Valley Hospital Charity is likely to approve please view our Grant Policy.

APPLICANT:

Applicants Name (required)

Job Title (required)

Where are you based? (required)

Darent Valley HospitalQueen Mary’s Sidcup

Telephone Number (required)

Email (required)

PROJECT/GRANT WANTED FOR:

Name of Project or Equipment (required)

Describe what the project or equipment will do? (required)

Please provide the name and contact details of a representative who could attend a Charity Management Board Meeting to talk about the request? (required)

Project cost (required)

Does your Line Manager support your request? (required)

YesNo

Managers Name (required)

Managers email address (required)

Have you secured a quote through Procurement? (required)

YesNo

If you are asking for a grant of over £5k has your Business Manager supported you with a Business Case for the Capital Investment Committee? (required)

YesNo (this stage needs to happen so please make them aware as it could hold up the grant approval)

Are there any extra costs/revenue implications - staffing, maintenance, consumables etc. that need to be considered? (required)

If the request is for a piece of equipment, please state its estimated life? (required)

Who will benefit, gender, age, group etc? (required)

Is there any department/ward crossover - will the proposal benefit other departments? (required)

Send