Equaliser Application

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Equaliser Fund aims to level the playing field for participants, by providing small one-off grants that remove an immediate barrier preventing them moving forward with an activity, learning or employment.

Referrer Information

Date of Application
One Together Team*	One Together Team is required
Staff Name	Staff Name is required Invalid characters: < > in Staff Name.
Staff Email*	Staff Email is required Staff Email is required Staff Email is not valid Invalid characters: < > in Staff Email.
Staff Contact Number*	Staff Contact Number is required Staff Contact Number is required Mobile Phone must be 11 digits
Staff Job Role	Staff Job Role is required

Applying on behalf of

Title*	Title is required
First Name*	Forename is required Forename is required Invalid characters: < > in Forename.
Surname (s)*	Surname is required Surname is required Invalid characters: < > in Surname.
Participant Address*	Postcode:* A postcode is required Building Name: Secondary Name: Street: District: Town: County:
Email Address	Email is required Email is not valid Invalid characters: < > in Email.
Mobile Phone	Mobile is required Invalid characters: < > in Mobile. Mobile Phone Number must be 11 digits
Other Number	Telephone is required Invalid characters: < > in Telephone. Telephone Number must be 11 digits

Household Status*	Drop 5 is required
QL Property Number	Invalid characters: < > in Text 6.

Equal Opportunities Policy

To ensure all our customers have equal access to services we ask for information about you when completing the application. The information requested will not in any way affect your application and is for statistical monitoring only and in no way effects the application

Date of Birth*

Date Of Birth is invalid, use the following format dd-mmm-yyyy
Date Of Birth is required

Age

Does the applicant describe themselves as having a disability?*

Drop 6 is required

Gender*

Male	Female	Transgender	Transsexual	Prefer not to say
Other	Non Binary

Which Ethnicity does the applicant describe themselves as*

asian/asian british - bangladeshi	asian/asian british - chinese
asian/asian british - indian	asian/asian british - pakistani
Asian, Asian British or Asian Welsh	asian/asian british - other
black/african/caribbean/black british - african	black/african/caribbean/black british - caribbean
black/african/caribbean/black british - other	Black, Black British, Black Welsh, Caribbean or African
mixed/multiple - white and asian	mixed/multiple - white and black african
mixed/multiple - white and black caribbean	mixed/multiple - other
Mixed or Multiple ethnic groups	white - english/welsh/scottish/northern irish/british
white - irish	white - roma, gypsy or irish traveller
Gypsy, Irish Traveller or Roma	white - other
other ethnic group - arab	White
other ethnic group - other	Other ethnic group

Ethnicity is required

Text 4 is required
Invalid characters: < > in Text 4.

Housing situation of referral

Are you a parent or Guardian of children 18 years old or under? or 19-24yrs old with additional needs?*	Yes No
Is it a Single Parent Household?*	Yes No
Does anyone in the household have a Disability?	Yes No
Does anyone in the household have a long-term health condition?	Yes No

People in the household (Adults & Children)

Number of Adults in the household (18+)*

Number of Adults in the household (18+) is required
Number of Adults in the household (18+) value out of range or not numeric.
Invalid characters: < > in Number of Adults in the household (18+).

Number of Children under 18*

Number of Children under 18 is required
Number of Children under 18 value out of range or not numeric.
Invalid characters: < > in Number of Children under 18.

Total occupants of house

Total occupants of house is required
Total occupants of house is required
Total occupants of house value out of range or not numeric.
Invalid characters: < > in Total occupants of house.

Type of Grant requested*

Household Support Essentials Fund

Type of Grant requested is required

explored the participants income and cannot identify other sources of money to cover cost is required

Confirm you have explored the participants income and cannot identify other sources of money to cover this cost*

referrer clear with participant this is application/funding not guaranteed is required

Referrer to tick to confirm they have been clear with the participant; this is an application process & the funding is not guaranteed. It needs to be checked by an independent person. *