Apply for a Butterfly Fund grant - 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)

First name Surname

Your job title(Required)

Your organisation(Required)

Please give the full name of the organisation itself, rather than the name of your team.

Organisation type(Required)

Your work email(Required)

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

Enter Email Confirm Email

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 is known to palliative care services/staff

The child died before their 19th birthday

The child died within the past eight weeks

The family is aware of the application submission

The family is willing to proceed with Together for Short Lives' Butterfly Fund grant process

Details of the parent/carer and child

Parent/carer name(Required)

First name Surname

This must be the name on the bank account that will receive the voucher.

Email address(Required)

This must be the email address linked to the bank account that will receive the voucher.

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City/town/village Postcode

Region(Required)

Relationship to child(Required)

Child's name(Required)

First name Surname

Child's medical condition/diagnosis(Required)

Child's date of birth(Required)

Child's date of death(Required)

What difference will a Butterfly Fund voucher make to this family?(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 voucher.

By submitting these details you confirm that you have consent from the family to share theirs for the purposes of processing this application and that you have let them know how to find our href="https://www.togetherforshortlives.org.uk/about-us/useful-information/privacy-policy/">privacy notice.

We take your privacy seriously, and information about how we protect and use your personal data is set out in the above policy. You can withdraw or update your consent to use your data in this way by calling0117 989 7820, emailing supportercare@togetherforshortlives.org.uk.

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Butterfly Fund referral form

Referrer's details

Details of the parent/carer and child

Ethnicity data (for monitoring purposes only)

Next steps