Jerry Farr Travel Fellowship

Part 1 - About you (the applicant)

Title:

Forename:

Surname:

Address:

Postcode:

Telephone:

Email:

Mobile number:

Are you a Friend of Ataxia UK?

Yes
No

If so, please quote your Friend’s Number:

Are you a member of a branch of Ataxia UK? If so, please give the name of that branch:

What type of ataxia do you have?

Are you in receipt of income support benefit?

Yes
No

In order to complete your application, please send us the following items which can either be scanned and emailed to fundraising@ataxia.org.uk or sent by post.
• At least one price quotation and/or brochure picture.
• Evidence that you are in receipt of income support benefit.
• A letter from your doctor stating that you are fit to travel and take part in any activities proposed during the trip

Part 2 - About the trip

Outline your proposal for this travel fund. Include the destination(s), itinerary and time frame and activities to be undertaken.

Please provide a detailed budget showing all the costs required for you to undertake this trip. Please include the cost of transport, accommodation, food, activities, travel insurance, vaccinations (if required), the cost of bringing a carer (if necessary) and any other expenses.

How will this trip provide a challenge for you?

Why should you be awarded this travel fellowship and what will you gain from the experience?

Are you prepared to take part in publicity for the travel fund?

Yes
No

I have read and agree to the all the terms & conditions

Helpline: 0845 644 0606

Jerry Farr Travel Fellowship

Part 1 - About you (the applicant)

Part 2 - About the trip