Grant application form

Thank you for choosing to complete CLIC Sargent's young people's self-referral grant application form.

You can use this application form to apply for a care grant if you are:

  • Aged 16-24 years
  • Are eligible for free NHS treatment within the UK
  • Have been diagnosed with a cancer diagnosis within the last 12 months

Please note that we will require verification of your details from one of your clinicians or cancer nurse specialists before the grant can be issued. CLIC Sargent will contact the named person to confirm the information provided is valid and correct.

You will need to provide details of your elected clinician or nurse including:

  • Position/ job title
  • Contact details (telephone and NHS email address)
  • Name and full address of the hospital where they work

Should you have any queries regarding the application process, please call us on 0208 752 2895.

If you are a parent completing this form on behalf of your child, please ensure you have permission to share their information and that you use their details when completing the application.

1 2 3 4
1 / 4
Your details
Your contact details