Property Impact Fund

This is a test form that can be deleted in July 2026

STRICTLY PRIVATE AND CONFIDENTIAL

Please fill in ALL sections of the form, unless stated otherwise. If you have any questions or need help with your application, contact us on equipmentgrants@musculardystrophyuk.org.

Who is completing this application?(Required)

Section One: About the applicant (the person who the equipment is for)

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is this address the same for the parent or gardian?

Yes

Email(Required)

Phone(Required)

Date Of Birth(Required)

Gender

Parent/guardian details

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Date of Birth(Required)

What is your relationship to the applicant?(Required)

Please specify your relationship to the applicant(Required)

Someone else helping to complete this application

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Date of Birth(Required)

What is your relationship to the applicant?(Required)

Please specify your relationship to the applicant(Required)

About the applicant’s condition

Do you have a diagnosed muscle wasting or weakening condition?(Required)

Yes

Please provide details of your condition:

Equipment request

Please give details of the equipment you are requesting, including model details and other specifications. A quotation for the equipment must be supplied as part of the application.

What type of equipment do you need support with?(Required)

Mobility and access equipment(Required)