PMSF UK AWARD APPLICATION FORM Criteria: The family must be registered with the Phelan-McDermid Syndrome Foundation. The PMS individual must be a UK or Ireland resident. The PMS individual should be registered with the International Patient International Registry (PMSIR). If the award application is successful, PMSF UK may request evidence of the activity or equipment through photographs, receipts, or activity enrolment. We would welcome this voluntarily to share with the wider community in order publicise the benefits of the awards programme. For each award please complete a separate application form. Please send the completed application form in Word format or photo/scan of completed form to: awards@pmsf.org.uk PMS Therapy Award PMS Sibling Award Award applied for (tick box) PMS Training / Education Award PMS Individual Equipment Award PMS Family Activity/Travel Award Name of person completing application form Relationship of applicant to PMS individual Name of PMS individual Date of Birth of PMS individual Address & Post Code Email address Telephone / Mobile Sibling Name (if application for sibling award) Sibling Date of Birth (if application for sibling award) Award value applied for (up to maximum value) Proposed use of award, for example contact details, cost and venue of activity or equipment supplier /training program. Yes No, but I would like support to register on the site (please PMSIR registered? (tick box) provide a mobile number and best time to be contacted) Bank Name Account Name Bank Details Account Sort Code Account Number Other comments (if applying for more than one award list priority, 1st choice, 2nd choice, etc.)
PMSF UK AWARD APPLICATION FORM Criteria: The family must be registered with the Phelan-McDermid Syndrome Foundation. The PMS individual must be a UK or Ireland resident. The PMS individual should be registered with the International Patient International Registry (PMSIR). If the award application is successful, PMSF UK may request evidence of the activity or equipment through photographs, receipts, or activity enrolment. We would welcome this voluntarily to share with the wider community in order publicise the benefits of the awards programme. For each award please complete a separate application form. Please send the completed application form in Word format or photo/scan of completed form to: awards@pmsf.org.uk Award applied for (tick box) PMS Therapy Award PMS Sibling Award PMS Training / Education Award PMS Individual Equipment Award PMS Family Activity/Travel Award Name of person completing application form Relationship of applicant to PMS individual Name of PMS individual Date of Birth of PMS individual Address & Post Code Email address Telephone / Mobile Sibling Name (if application for sibling award) Sibling Date of Birth (if application for sibling award) Award value applied for (up to maximum value) Proposed use of award, for example contact details, cost and venue of activity or equipment supplier /training program. PMSIR registered? (tick box) Yes No, but I would like support to register on the site (please provide a mobile number and best time to be contacted) Bank Details Bank Name Account Name Account Sort Code Account Number Other comments (if applying for more than one award list priority, 1st choice, 2nd choice, etc.)
PMSF-UK-Award-Application-Form-2018.docx