S&HCFA - Benevolent Fund Applications

S&HCFA - Benevolent Fund Applications

Applicant Details

Full Name

Address (Including postcode)

Email Address

Contact Tel (Home)

Contact Tel (Mobile)

Role in football

Select or enter value

Occupation

Under what circumstances was the injury sustained?

Select or enter value

Please provide details of injury

Date the injury occurred

Please provide the fixture the injury occurred in?

Period of incapacity (in weeks)

Normal WEEKLY NET income prior to incapacity

WEEKLY NET income during period of incapacity

Additional payments received to supplement income

This may include donations, additional work related sick pay etc

Personal Accident Insurance Provider

FA regulations state that all participants (junior and senior) must be covered under a Personal Accident (PA) policy.

Total £ claimed via Personal Accident Insurer

Private Healthcare Provider (if applicable)

Total £ claimed from Private Healthcare Provider

Have you received a Benevolent Fund grant before?

Select or enter value

If YES, please provide details below.

Please include the year and the grant value received.

File Upload

Please use the section below to upload any information you wish to be considered alongside your application (images, print screens, documents)

Drag and drop files here or

Send me a copy of my responses