Bursary Application Form Bursary Application Form The Different Strokes Bursary Fund is a collaboration with various rehabilitation centres across the UK to deliver a high-quality service benefiting individuals no longer under NHS care or unable to afford private physiotherapy or rehab services. Different Strokes is also happy to share information about a free physiotherapy service for stroke survivors from the University of Birmingham for people in the West Midlands area. Options include an intensive five week neuro-rehab programme, an out-patient clinic and an open gym drop-in session. For more information and eligibility please visit their website HERE. To complete their referral form please visit HERE. Please note that this scheme is completely independent of the Different Strokes bursary scheme, and all arrangements should be made with the University of Birmingham. We are unable to answer any queries relating to this scheme - Please contact the university directly.EligibilityPlease tick the criteria to confirm eligibility(Required) I am between 18-65 years of age I am able to travel to the clinic I have applied to (or they do home visits) I can transfer in and out of transport with minimal assistance from a carer (handling belt is acceptable) I have some level of mobility, but am unable to walk long distances independently without a walking aid I am not currently receiving any statutory (NHS) physiotherapy or rehabilitation My stroke was more than 3 months prior to this application I understand that I will be required to make some financial contribution based on my income Select AllPersonal detailsName First Last Address(Required) Street Address Address Line 2 City County Post Code Email(Required) Phone(Required)Date of birth(Required) DD slash MM slash YYYY EthnicityAsian or Asian British: IndianAsian or Asian British: PakistaniAsian or Asian British; BangladeshiAsian or Asian British: ChineseAsian or Asian British: Any other Asian backgroundBlack or Black British: CaribbeanBlack or Black British: AfricanBlack or Black British: Any other Black or Black BritishMixed or multiple ethnic groups: White and Black CaribbeanMixed or multiple ethnic groups: White and Black AfricanMixed or multiple ethnic groups: White and AsianMixed or multiple ethnic groups: Any other mixed or multiple ethnic backgroundWhite: English, Welsh, Scottish, Northern Irish or BritishWhite: IrishWhite: Gypsy or Irish TravellerWhite: RomaWhite: Any other white backgroundArabAny other ethnic groupPrefer not to sayInformation about your strokeDate of stroke(Required) DD slash MM slash YYYY If you don't know the exact date, don't worry, but please ensure the month and year are correct.Please give details of the physical impairments you have post stroke. How do these physical impairments affect your daily life? Please use specific examples, such as unable to cook or unable to walk my children to school.(Required)What would be your desired outcomes from physical rehabilitation - how would this improve your daily life?(Required)What previous physiotherapy for stroke rehabilitation have you had? If you are still receiving statutory (NHS) physio please do not apply until this is finished.(Required)NET MONTHLY Income InformationPlease state total NET MONTHLY income and expenditure for your household. This should include income and expenditure of other adults living in the household. This information will be used to assess your eligibility and the potential amount of a bursary awarded so please ensure that you complete this as accurately as possible. Non-disclosure of any income may invalidate your application. You may be asked to provide evidence of income and expenditure at any point during the application process.Please type 0 in any boxes that are not relevant to your situation.NET MONTHLY wage and or pension of household(Required)Total of any government benefits including child benefit(Required)Child maintenance being received(Required)Any other income not listed above(Required)Savings(Required)MONTHLY Expenditure InformationMortgage or rent(Required)Household bills (utilities, council tax, broadband, Insurance, phones etc)(Required)Food(Required)Childcare(Required)Combined MONTHLY repayments of loans & credit cards(Required)Child maintenance payable(Required)Vehicle / travel costs(Required)All other outgoings such as - clothing/entertainment/subscriptions/personal care - Please include costs relating to private care agencies and related sundries.(Required)Have you applied to the Different Strokes bursary fund before?(Required) Yes No Clinic I would like to apply to if my application is successful(Required)Physiofunction (Northamptonshire)Neuro Physio (Scotland)Motion Rehab (Yorkshire)Therapy Matters (Chester)Hobbs Rehabilitation (Hampshire, Wiltshire, Berkshire, Dorset areas)Birkdale Paediatric and Adult Neuro Clinic (Isleworth, West London))Neuro Rehab Practice (Richmond-upon-Thames, South London)Morrello ( Newport, Wales)Cambridge Neuro Physiotherapy (Cambridgeshire)Benfleet Physiotherapy (Essex)NR WalesPlymouth Neurophysio (Plymouth)Vim Healthcare (Sussex)Therapy Gyms (Suffolk/Essex)Pathways Physiotherapy (Burton-on-Trent)Well Way Rehab Solutions (Bromsgrove)Surrey Hills Rehab (Surrey and North Sussex)If you require a home visit please check that the clinic you have selected are able to accommodate home visits and cover your area. You can do this by checking the bursary page on our website. From time to time Different Strokes would like to use case studies of successful applicants for ongoing promotion and awareness of the bursary scheme. Are you happy for your feedback and pictures to be used in this way?(Required) Yes No Do you have any further comments or questions? If you are applying for or have already recieved bursary awards from other charities or organisations, please let us know here.FileMax. file size: 2 GB. Δ
