John Chard-Young Legacy Fund - application for A.I.M Health & Wellness Centre sessions

A.I.M Health & Wellness Centre sessions – these sessions can include access to the wellbeing suite where you are able to use exercise machines that are low impact and power assisted, under the guidance of instructors. This can be taken up as 12 sessions and must be used within a six-month period. Or, in partnership with Rockingham Forest Wellbeing, you can access holistic therapies such as osteopathy, sports massage, acupuncture and injury rehabilitation.

Section 1 - Contact details

Person applying for sport sessions

Applicant name

Address Line 1

This should be the address of the organisation. If the organisation doesn't have an independent location you can use the contact details of the primary contact.

Town/city

County

Postcode

Telephone

Email address

The telephone number and email address should be one at which the organisation is easily contacted, especially during office hours

Date of birth

Are you a member of one of the following organisations?

Adrenaline AlleyActive in Motion (A.I.M)BothYou must be a member of Adrenaline Alley and/or Active In Motion to apply

Do you have a disability or have any access or communication requirements you would like A.I.M and/or Adrenaline Alley to be made aware of?

If you are helping someone to apply, please provide your details:

If the individual applying for support is under the age of 16, please provide details of a parent/carer here.

Forename

Surname

Relationship to applicant

Organisation (if applicable)

Work/Office Phone

Home Phone

Mobile Phone

Address Line 1

Town/City

Postcode

Section 2 - Request for support

Please describe why you would like and are in need of support to access wellbeing sessions through Active In Motion or Rockingham Forest Wellbeing (you may wish to include information on your financial circumstances)

Which of the following would you prefer:

12 x sessions at Active In MotionRockingham Forest Wellbeing sessions (such as osteopathy, sports massage, acupuncture and injury rehabilitation)

Have you received a bursary before? If so when?

If this application is not awarded will you be able to access wellbeing support any other way?

Have you contacted your GP or community organisations to access support?

Section 3 - Supporting documents and Declaration

Supporting Documents

Please provide a recent copy of your bank statement with this application.

Documents to Follow in Post

Yes

Bank Statement

Declaration

I confirm that I meet the eligibility criteria listed in the guidance notes to apply to this fund. I give permission to Northamptonshire Community Foundation to record the information in this form electronically for the purpose of grant management. I give permission for Northamptonshire Community Foundation to contact Adrenaline Alley, Active In Motion, Rockingham Forest Wellbeing and/or other treatment providers (where applicable) to confirm and share information about my application.

Declaration Approved

Yes

Contact Information