Please Note: We cannot accept requests from individuals themselves.
This form must be completed by a third party responsible for referring the individual for a grant. After you submit the form, it will be emailed to the address given at the end of the form (Referrer details – contact email) so that you can reuse the information given to assist you with other grant applications. 

Grant recipient details



Date of Birth


01. Living arrangements – does the applicant have any dependents or other adults living with them? Is the applicant a home owner or renting?

02. Health issues - do they have any disabilities or chronic health issues, mobility problems etc?

03. Financial situation – does the applicant receive any pensions, benefits or allowances (please give details). Does the applicant have any savings or any significant outgoings, debts etc?

04. Family support - Does the applicant have family support and if so are family members able to contribute financially? (It is useful to rule this out before contacting the Society)

05. Grant requested details - what is the grant application for and how much is being requested? How will this improve quality of life? Please include quotes for any proposed work or item. We have a preferred supplier for carpets/flooring, but require a contact telephone number to arrange a visit to take measurements and quote.

Referrer details



Contact number

Contact email

WEC&R c-log reference number or other accounts reference if applicable

06. Fundraising - Have you applied to any other charities? If so please list those you will be or have applied to and how much pledged by any so far and how much you have left to raise.

Attach a file

Attach a file

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Registered charity: CIO 1167933

The Anchor Society,
29 Alma Vale Road, Clifton, Bristol BS8 2HL