Butterfly Fund Referral Form - Together for Short Lives

Referrer's details

This information will enable us to assess that you are authorised to complete an application to the Butterfly Fund on a family’s behalf

Your name(Required)

Your job title(Required)

Your work email(Required)

You must use the email address of your employer – any personal emails will be rejected.

Enter Email Confirm Email

How are you known to the family?(Required)

Please confirm all of the following(Required)

The child of the family you are referring for a Butterfly Fund grant was diagnosed with a life-limiting/life-threatening health condition before their death

The family are known to palliative care services/staff

The child died before their 19th birthday

The child died within the past 8 weeks

The family has given verbal consent for their information to be shared with Together for Short Lives to be referred for a Butterfly Fund grant

The family is aware that we will contact them directly to request bank details should the referral be successful

Details of the child and family

Parent/carer name(Required)

Relationship to child(Required)

Email address of parent/carer(Required)

Town/county of residence(Required)

Child’s name(Required)

Child's medical condition/diagnosis(Required)

Child’s date of birth(Required)

Child's date of death(Required)

Ethnicity data (for monitoring purposes only)

Please choose the option that best describes the child's ethnicity

Next steps

Once this referral has been authorised, we will contact the family by email with a unique application code and a link to a secure site to share bank details.

Families are required to submit bank details within 4 weeks of receiving the link.

These details will be held for 2 years for audit purposes only and in line with our Data Privacy Policy.

Butterfly Fund Family referral form

Referrer's details

Details of the child and family

Ethnicity data (for monitoring purposes only)

Next steps