"*" indicates required fields Step 1 of 5 20% Organisation name* Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Status*Registered CharityRegulated BodyOther (please specify)Other Registration no. Date your organisation/service was formed* DD slash MM slash YYYY Website* Facebook Instagram X (Previously Twitter) TikTok Primary contact* First Last Email address* Phone number* Section 2 – Your mission, objectives and activitiesDescribe your organisation’s mission and objectives.*(Max 1,000 characters)Tell us about the people you support.*How old are they, what clinical and care needs do they have, what are their challenges (Max 1,000 characters)What is your track record of delivering services for children and young people with life-limiting conditions?*Tell us what services you provide, where you provide them and what impact they have had. (Max 1,000 characters)How many children with life-limiting conditions do you support on average per year?* Section 3 – Application for Lifelites supportTell us about the project or services that you are seeking support for.*Is it a new or existing service? How would you use assistive technology in your services? Where, when, how often and during what services or activities you would use technology with children (Max 1,500 characters)How would assistive technology complement or add value to your existing services?*Please reference the needs of the children you support, what challenges they face, how do you know that they would benefit. (Max 1,000 characters)How many children with life-limiting conditions and complex needs do you expect to benefit?*How many staff/volunteers do you expect to use this technology?*What are the expected outcomes?*Tell us about the difference this will make to children, their families and your service and how will you measure this. (Max 1,000 characters) Section 4 – Assistive technology requestedWhen filling out your technology requests, please be aware that you can apply for up to £25,000 worth of technology.Eyegaze Quantity Price: £ 5,000.00 Quantity Magic Carpet Quantity Price: £ 7,700.00 Quantity Interactive Entertainment Hub Quantity Price: £ 4,300.00 Quantity GoPro Camera Bundle Quantity Price: £ 600.00 Quantity Switch Toy Quantity Price: £ 50.00 Quantity Meta Quest 3 & games Quantity Price: £ 650.00 Quantity iClick Quantity Price: £ 250.00 Quantity Cosmo Quantity Price: £ 700.00 Quantity iPad with case and extras Quantity Price: £ 650.00 Quantity iPad charging station Quantity Price: £ 900.00 Quantity Tilt Table Quantity Price: £ 4,200.00 Quantity POD tent - Large Quantity Price: £ 1,200.00 Quantity POD tent - Small Quantity Price: £ 1,050.00 Quantity POD extra themes Quantity Price: £ 285.00 Quantity Wildlife Window (max. cost) Quantity Price: £ 650.00 Quantity Switches (max. cost) Quantity Price: £ 250.00 Quantity Total How will this technology be used?*What difference will it make to children? (Max 2,000 characters)Please let us know any other assistive technology you have identified and would like us to consider, including quantity and price Section 5 - Additional InformationPlease provide any further information you feel is relevant to this applicationPlease upload a copy of your children’s safeguarding policy (and vulnerable adults if applicable)*Max. file size: 32 MB.Please upload a copy of your most recent accounts*Max. file size: 32 MB.NameThis field is for validation purposes and should be left unchanged.