DonMentia Grant Application – General Please answer all questions as failure to complete the form fully and accurately may result in your application being rejected or delayed. 1. Full name of applicant and status of the applicant to person with dementia, e.g husband carer, daughter carer etc.. Applicant's Name (required) Status (required) Name of person with a diagnosis of dementia (required) Please explain what items you which to purchase and how these items will improve quality of life 3. Funding a) What is the total cost of the item(s)? b) How much is being sought from DonMentia to fund this? c) Where, if any, is additional money coming from? e.g self-funded, respite vouchers etc. d) What specifically will the DonMentia grant funds be spent on? e) Who will benefit from the spending of DonMentia Grant Funds? e.g. yourself, carers and please give a brief description of how you/they will benefit. f) Please use this space for any additional information Your Email (required) Address Phone number (required) This form will be sent directly to email@example.com - you should shortly receive a confirmation email.