Application form

Before completing the following application form, please take a few minutes to familiarise yourself with the our guidance booklet, which sets out grant eligibility and grant scope. You can download and read in full here: DOWNLOAD
    Contact details
    This should be the details of either the applicant (attending adult patient), or a primary contact making this application on behalf of another (i.e. the parent/guardian or carer)
    Applicant details 

    Eligibility 
    Please complete the following fully so that we can assess your eligibility for grant support.
    Existing benefits
    NHS - Healthcare Travel Costs Scheme (HTCS)
    Please note: Only applicants who have sough reimbursement via the HTCS route in the first instance, and been unsuccessful will be considered for our grant.  If you have not yet tried this, we suggest you do so before submitting a request to us. Find out more here: ​ www.nhs.uk/nhs-services/help-with-health-costs/healthcare-travel-costs-scheme-htcs/
    About your medical appointment

    Important notes: Please note that only appointments that are part of the National XP Service at the Rare Disease Centre, St Thomas' Hospital, London, routine appointments process, are covered by this grant process. Please see our guidance booklet for advice on funding for additional medical appointments.
    About your costs (travel and accommodation)
    The maximum value of our grants is £250.00 which is allocated based on your region of travel and personal needs. Please provide as much detail as you can below to help us assess the level of reimbursement you will receive.

    Bank Details

    Disclaimer

    By submitting this application, I declare the following to be true, and acknowledge that should it be found to be otherwise my application will be made void and it will affect my ability to apply for future support from Action for XP.  Fraudulent claims will be reported to the correct authority.
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Keeping in touch
    ​In order that we can keep you up to date with our services that may benefit you, and other relevant XP news, we would like your permission to add you to our patient and family Database.  We will only contact you when we have have relevant information, services and projects which you can benefit from. We do not share your details with any 3rd party, and you can read our data protection policy here: Privacy Policy

    Should you need any help completing this form, or uploading the required supporting documentation, please email Kelly via admin@actionforxp.org and she will be very happy to help.