I am completing this form on behalf of my client who is deemed to be the applicant. The personal information I am providing about the applicant is accurate to my knowledge.
I have explained to the applicant that, in making this referral, I am sharing their personal data, including health information, and they have agreed to this. I have explained that Independence at Home will be using the information to assess their grant application.
I confirm that I have explained the application process and have the permission of the applicant to share all the information included within this grant application. (Please note that we are unable to consider grant applications where you do not have permission to share such information.)
If the application is successful, I agree to receive a short monitoring questionnaire and to complete this in relation to the grant that has been awarded by Independence at Home.