Alertlines 4 Carers Application Form

Please fill in all the fields marked *

  • Agency Details

  • Carers Details

  • DD slash MM slash YYYY
  • Information about the grant you are applying for:

    Working in partnership with Connected Living we are offering FREE installation and the first TWO MONTHS FREE for Connected Living – At Home Package. This will include a monitored Home Alarm and Pendant. Connected Living will undertake an assessment with the customer and Carer during the installation. Further funding may be available from The Leonardo Trust for an extended service, additional equipment or a keysafe if required.
  • The Leonardo Trust:

    I understand that all information supplied on this application form to Leonardo Trust will be kept strictly confidential and will only be used for the purpose of selection and administration. The information I have given in this application is, to the best of my knowledge, true and accurate. I accept that any false or misleading statements may be sufficient cause for rejecting an application. A copy of our Grant Making Policy is available on our website, or alternatively from our Broadstone office.
  • Connected Living:

    I understand that if funding has been agreed, this information will be shared with Connected Living who will carry out the installation and store my information in accordance with Data Protection Law. More details can be found on our website:
  • Note:

    The trustees regret we are unable to reimburse costs already paid or anything that has been booked, contracted for, or reserved prior to our agreement to fund/part-fund the cost.