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with-bg-image"> <div class="header-banner header-banner-hero header-banner-hero--left header-banner-hero--y-bottom header-banner--dark header-banner--no-mobile-content recite-ignore-styles-background" style="background-image: url('https://www.younglivesvscancer.org.uk/wp-content/smush-webp/2018/08/Josh-dad-Aug2018-1440x399-grants-e1538063320595.jpg.webp'); background-repeat: no-repeat; background-size: cover; background-color: #fff; background-position: top center;" data-smush-webp-fallback="{"bg-image":" url('https:\/\/www.younglivesvscancer.org.uk\/wp-content\/uploads\/2018\/08\/Josh-dad-Aug2018-1440x399-grants-e1538063320595.jpg')"}"> <div class="container-fluid recite-ignore-styles-background"> <div class="header-banner-hero__content with-bg-image"> <div class="header-banner-hero__content-inner recite-ignore-styles-background"> <h1 class="recite-ignore-styles-background">Cancer Costs <br>We can help</h1> </div> </div> </div> </div> <div class="header-banner-hero__content-mobile"> <h1 class="recite-ignore-styles-background">Cancer Costs <br>We can help</h1> </div> </div> <div class="main-content-wrapper"> <div id="primary" class="content-area"> <main id="main" class="site-main " role="main"> <style> .filter-badge { color: #fff; background-color: #020a0a; display: inline-block; padding: .25em .4em; font-size: 75%; font-weight: 400; line-height: 1; text-align: center; white-space: nowrap; vertical-align: baseline; border-radius: .25rem; margin: 5px; } .filter-row { display: inline-block; text-align:center; width: 100%; } </style> <div id="page-categories-nav"> </div> <div class="content-block content-block--sidebar"> <div class="content"> <div class="container-fluid"> <div class="row"> <div class=" col-lg-8 offset-lg-2"> <h1 class="heading-pull-top">Get a Young Lives vs Cancer grant</h1> </div> <div class=" col-lg-8 offset-lg-2"> <div class="section-intro--text"> <p>It’s not right that young people and parents have to worry about money when they need to focus on treatment and all that comes with it. So Young Lives vs Cancer offers various grants for cancer patients, right from the moment of diagnosis, to help young people and families cope financially.</p> </div> </div> </div> </div> <div class="container-fluid"> <div class="row"> <div class=" col-lg-8 offset-lg-2"> <div class="flexible-block wysiwyg"> <h2>Our Registration Grant</h2> <p>Cancer costs from the moment of diagnosis, but there’s no financial support sitting there waiting for you. To help with the immediate costs of cancer, we give a grant of £100 following an initial or secondary cancer diagnosis. You can also apply for this grant if you have received a relapse diagnosis a year or more after your previous treatment ending. Most young people and families use it to cover sudden expenses like:</p> <ul> <li>Travel to and from hospital, and parking there</li> <li>Extra food costs</li> <li>Increasing household bills and essential items</li> <li>Increasing phone bills so you can keep in touch with family and friends</li> <li>Private tuition to reduce the impact on education</li> <li>Accommodation near the hospital</li> <li>Childcare for siblings</li> </ul> </div> </div> </div> </div> <div class="container-fluid"> <div class="row"> <div class=" col-lg-8 offset-lg-2"> <div class="flexible-block wysiwyg"> <h2>How to apply</h2> <p>If you are a young person aged 18-24 diagnosed with cancer, or a parent of a child aged 0-17 diagnosed with cancer, you can apply for this grant by filling out the application form below.</p> <p>If you are younger than 18 and unable to have a parent to complete the form on your behalf, please give us a call on the number below.</p> <p>*<strong>Please note if you have been assigned a Young Lives vs Cancer Social worker, you may have already received the registration grant and won’t be eligible to apply again. If you are unsure you’ve received it, please check with your assigned Young Lives vs Cancer Social worker</strong>*</p> <p>If you want to check whether you’re eligible, or need help completing this form you can contact our Central Support team on 0300 303 5220, <a href="mailto:getsupport@younglivesvscancer.org.uk">getsupport@younglivesvscancer.org.uk</a> or by using Live Chat.</p> <p>Your details are safe with us. For more information about how Young Lives vs Cancer uses your information, please read our <a href="https://www.younglivesvscancer.org.uk/privacy-policy/">Services Privacy Notice.</a></p> <style>#field_21_62>div.admin-hidden-markup>span{display:none}</style> </div> </div> </div> </div> <div class="container-fluid"> <div class="row"> <div class=" col-lg-8 offset-lg-2"> <div class="flexible-block gravity-form"> <script type="text/javascript"></script> <div class='gf_browser_chrome gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_21' style='display:none'><div id='gf_21' class='gform_anchor' tabindex='-1'></div><form method='post' enctype='multipart/form-data' target='gform_ajax_frame_21' id='gform_21' action='/what-we-do/financial-support/grants/#gf_21' data-formid='21' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Ld8ZwMqAAAAADAlsvoL91vHS4h4IHDP8h3l4GiJ' data-tabindex='0'><input id="input_3990c708791f205d06b45b22878cd4ed" class="gfield_recaptcha_response" type="hidden" name="input_3990c708791f205d06b45b22878cd4ed" value=""/></div> <div class='gform-body gform_body'><ul id='gform_fields_21' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id="field_21_34" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_34" ><h2>Eligibility Criteria</h2> </li><li id="field_21_87" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_87" ><label class='gfield_label gform-field-label' >I confirm that my child/I<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_87'> <li class='gchoice gchoice_21_87_0'> <input name='input_87' type='radio' value='Received a confirmed cancer or bone marrow failure disorder diagnosis from an NHS cancer or haematology service. Or have benign and low grade diagnoses which have cancer-like behaviour where there is a high burden of treatment.' id='choice_21_87_0' /> <label for='choice_21_87_0' id='label_21_87_0' class='gform-field-label gform-field-label--type-inline'>Received a confirmed cancer or bone marrow failure disorder diagnosis from an NHS cancer or haematology service. Or have benign and low grade diagnoses which have cancer-like behaviour where there is a high burden of treatment.</label> </li></ul></div></fieldset></li><li id="field_21_91" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_91" ><label class='gfield_label gform-field-label' >I confirm that my child/I<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_91'> <li class='gchoice gchoice_21_91_0'> <input name='input_91' type='radio' value='Received the diagnosis before their/my 25th birthday and also within the last 12 months.' id='choice_21_91_0' /> <label for='choice_21_91_0' id='label_21_91_0' class='gform-field-label gform-field-label--type-inline'>Received the diagnosis before their/my 25th birthday and also within the last 12 months.</label> </li></ul></div></fieldset></li><li id="field_21_90" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_90" ><label class='gfield_label gform-field-label' >I confirm that my child/I<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_90'> <li class='gchoice gchoice_21_90_0'> <input name='input_90' type='radio' value='Qualify for free NHS cancer treatment in the UK, including members of (or children of) HM Armed Forces and diplomatic core/embassies.' id='choice_21_90_0' /> <label for='choice_21_90_0' id='label_21_90_0' class='gform-field-label gform-field-label--type-inline'>Qualify for free NHS cancer treatment in the UK, including members of (or children of) HM Armed Forces and diplomatic core/embassies.</label> </li></ul></div><div class='gfield_description' id='gfield_description_21_90'><p paraeid="{871377cc-cab5-47e2-b44c-fe501de2a739}{128}" paraid="167527125">It doesn’t matter whether a child or young person is under the care of a paediatric, teenage & young adult, or adult service – the eligibility criteria is the same. </p> <p paraeid="{871377cc-cab5-47e2-b44c-fe501de2a739}{143}" paraid="765239481">If you have any questions about our eligibility criteria please get in touch at <a href="mailto:getsupport@younglivesvscancer.org.uk">getsupport@younglivesvscancer.org.uk</a> or call us on 0300 303 5220. </p> </div></fieldset></li><li id="field_21_92" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_92" ><h2>Young Person's Details</h2> <p>If you are the parent of a child aged 0-15, please complete this form on their behalf (using their name, DOB, etc. but using your contact and payment details).</p> </li><li id="field_21_10" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_10" ><label class='gfield_label gform-field-label' for='input_21_10'>Child or Young Person Title<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_21_10' class='small gfield_select' aria-required="true" aria-invalid="false" ><option value='' >- Select -</option><option value='Dr' >Dr</option><option value='Miss' >Miss</option><option value='Mr' >Mr</option><option value='Mrs' >Mrs</option><option value='Ms' >Ms</option><option value='Other' >Other</option></select></div></li><li id="field_21_12" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_12" ><label class='gfield_label gform-field-label' for='input_21_12'>Child or Young Person First Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_21_12' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_13" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_13" ><label class='gfield_label gform-field-label' for='input_21_13'>Child or Young Person Last Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_21_13' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_27" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_27" ><label class='gfield_label gform-field-label' for='input_21_27'>Child or Young Person Date of birth<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_date'> <input aria-describedby='field_21_27_dmessage' name='input_27' id='input_21_27' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon' placeholder='dd/mm/yyyy' aria-describedby="input_21_27_date_format" aria-invalid="false" aria-required="true"/> <span id='input_21_27_date_format' class='screen-reader-text'>DD slash MM slash YYYY</span> </div> <input type='hidden' id='gforms_calendar_icon_input_21_27' class='gform_hidden' value='https://www.younglivesvscancer.org.uk/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg'/></li><li id="field_21_75" class="gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_75" ><label class='gfield_label gform-field-label' for='input_21_75'>Child or Young Person Gender</label><div class='ginput_container ginput_container_select'><select name='input_75' id='input_21_75' class='medium gfield_select' aria-invalid="false" ><option value='- Select -' >- Select -</option><option value='Male' >Male</option><option value='Female' >Female</option><option value='Undisclosed' >Undisclosed</option></select></div></li><li id="field_21_69" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_69" ><label class='gfield_label gform-field-label' for='input_21_69'>Child or Young Person Nationality<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_select'><select name='input_69' id='input_21_69' class='medium gfield_select' aria-required="true" aria-invalid="false" ><option value='Unknown' >Unknown</option><option value='Afghan' >Afghan</option><option value='Albanian' >Albanian</option><option value='Algerian' >Algerian</option><option value='American' >American</option><option value='Andorran' >Andorran</option><option value='Angolan' >Angolan</option><option value='Anguillan' >Anguillan</option><option value='Argentine' >Argentine</option><option value='Armenian' >Armenian</option><option value='Australian' >Australian</option><option value='Austrian' >Austrian</option><option value='Azerbaijani' >Azerbaijani</option><option value='Bahamian' >Bahamian</option><option value='Bahraini' >Bahraini</option><option value='Bangladeshi' >Bangladeshi</option><option value='Barbadian' >Barbadian</option><option value='Belarusian' >Belarusian</option><option value='Belgian' >Belgian</option><option value='Belizean' >Belizean</option><option value='Beninese' >Beninese</option><option value='Bermudian' >Bermudian</option><option value='Bhutanese' >Bhutanese</option><option value='Bolivian' >Bolivian</option><option value='Botswanan' >Botswanan</option><option value='Brazilian' >Brazilian</option><option value='British' >British</option><option value='British Virgin Islander' >British Virgin Islander</option><option value='Bruneian' >Bruneian</option><option value='Bulgarian' >Bulgarian</option><option value='Burkinan' >Burkinan</option><option value='Burmese' >Burmese</option><option value='Burundian' >Burundian</option><option value='Cambodian' >Cambodian</option><option value='Cameroonian' >Cameroonian</option><option value='Canadian' >Canadian</option><option value='Cape Verdean' >Cape Verdean</option><option value='Cayman Islander' >Cayman Islander</option><option value='Central African' >Central African</option><option value='Chadian' >Chadian</option><option value='Chilean' >Chilean</option><option value='Chinese' >Chinese</option><option value='Citizen of Antigua and Barbuda' >Citizen of Antigua and Barbuda</option><option value='Citizen of Bosnia and Herzegovina' >Citizen of Bosnia and Herzegovina</option><option value='Citizen of Guinea-Bissau' >Citizen of Guinea-Bissau</option><option value='Citizen of Kiribati' >Citizen of Kiribati</option><option value='Citizen of Seychelles' >Citizen of Seychelles</option><option value='Citizen of the Dominican Republic' >Citizen of the Dominican Republic</option><option value='Citizen of Vanuatu' >Citizen of Vanuatu</option><option value='Colombian' >Colombian</option><option value='Comoran' >Comoran</option><option value='Congolese (Congo)' >Congolese (Congo)</option><option value='Congolese (DRC)' >Congolese (DRC)</option><option value='Cook Islander' >Cook Islander</option><option value='Costa Rican' >Costa Rican</option><option value='Croatian' >Croatian</option><option value='Cuban' >Cuban</option><option value='Cymraes' >Cymraes</option><option value='Cymro' >Cymro</option><option value='Cypriot' >Cypriot</option><option value='Czech' >Czech</option><option value='Danish' >Danish</option><option value='Djiboutian' >Djiboutian</option><option value='Dominican' >Dominican</option><option value='Dutch' >Dutch</option><option value='East Timorese' >East Timorese</option><option value='Ecuadorean' >Ecuadorean</option><option value='Egyptian' >Egyptian</option><option value='Emirati' >Emirati</option><option value='English' >English</option><option value='Equatorial Guinean' >Equatorial Guinean</option><option value='Eritrean' >Eritrean</option><option value='Estonian' >Estonian</option><option value='Ethiopian' >Ethiopian</option><option value='Faroese' >Faroese</option><option value='Fijian' >Fijian</option><option value='Filipino' >Filipino</option><option value='Finnish' >Finnish</option><option value='French' >French</option><option value='Gabonese' >Gabonese</option><option value='Gambian' >Gambian</option><option value='Georgian' >Georgian</option><option value='German' >German</option><option value='Ghanaian' >Ghanaian</option><option value='Gibraltarian' >Gibraltarian</option><option value='Greek' >Greek</option><option value='Greenlandic' >Greenlandic</option><option value='Grenadian' >Grenadian</option><option value='Guamanian' >Guamanian</option><option value='Guatemalan' >Guatemalan</option><option value='Guinean' >Guinean</option><option value='Guyanese' >Guyanese</option><option value='Haitian' >Haitian</option><option value='Honduran' >Honduran</option><option value='Hong Konger' >Hong Konger</option><option value='Hungarian' >Hungarian</option><option value='Icelandic' >Icelandic</option><option value='Indian' >Indian</option><option value='Indonesian' >Indonesian</option><option value='Iranian' >Iranian</option><option value='Iraqi' >Iraqi</option><option value='Irish' >Irish</option><option value='Israeli' >Israeli</option><option value='Italian' >Italian</option><option value='Ivorian' >Ivorian</option><option value='Jamaican' >Jamaican</option><option value='Japanese' >Japanese</option><option value='Jordanian' >Jordanian</option><option value='Kazakh' >Kazakh</option><option value='Kenyan' >Kenyan</option><option value='Kittitian' >Kittitian</option><option value='Kosovan' >Kosovan</option><option value='Kuwaiti' >Kuwaiti</option><option value='Kyrgyz' >Kyrgyz</option><option value='Lao' >Lao</option><option value='Latvian' >Latvian</option><option value='Lebanese' >Lebanese</option><option value='Liberian' >Liberian</option><option value='Libyan' >Libyan</option><option value='Liechtenstein citizen' >Liechtenstein citizen</option><option value='Lithuanian' >Lithuanian</option><option value='Luxembourger' >Luxembourger</option><option value='Macanese' >Macanese</option><option value='Macedonian' >Macedonian</option><option value='Malagasy' >Malagasy</option><option value='Malawian' >Malawian</option><option value='Malaysian' >Malaysian</option><option value='Maldivian' >Maldivian</option><option value='Malian' >Malian</option><option value='Maltese' >Maltese</option><option value='Marshallese' >Marshallese</option><option value='Martiniquais' >Martiniquais</option><option value='Mauritanian' >Mauritanian</option><option value='Mauritian' >Mauritian</option><option value='Mexican' >Mexican</option><option value='Micronesian' >Micronesian</option><option value='Moldovan' >Moldovan</option><option value='Monegasque' >Monegasque</option><option value='Mongolian' >Mongolian</option><option value='Montenegrin' >Montenegrin</option><option value='Montserratian' >Montserratian</option><option value='Moroccan' >Moroccan</option><option value='Mosotho' >Mosotho</option><option value='Mozambican' >Mozambican</option><option value='Namibian' >Namibian</option><option value='Nauruan' >Nauruan</option><option value='Nepalese' >Nepalese</option><option value='New Zealander' >New Zealander</option><option value='Nicaraguan' >Nicaraguan</option><option value='Nigerian' >Nigerian</option><option value='Nigerien' >Nigerien</option><option value='Niuean' >Niuean</option><option value='Northern Irish' >Northern Irish</option><option value='North Korean' >North Korean</option><option value='Norwegian' >Norwegian</option><option value='Omani' >Omani</option><option value='Pakistani' >Pakistani</option><option value='Palauan' >Palauan</option><option value='Palestinian' >Palestinian</option><option value='Panamanian' >Panamanian</option><option value='Papua New Guinean' >Papua New Guinean</option><option value='Paraguayan' >Paraguayan</option><option value='Peruvian' >Peruvian</option><option value='Pitcairn Islander' >Pitcairn Islander</option><option value='Polish' >Polish</option><option value='Portuguese' >Portuguese</option><option value='Prydeinig' >Prydeinig</option><option value='Puerto Rican' >Puerto Rican</option><option value='Qatari' >Qatari</option><option value='Romanian' >Romanian</option><option value='Russian' >Russian</option><option value='Rwandan' >Rwandan</option><option value='Salvadorean' >Salvadorean</option><option value='Sammarinese' >Sammarinese</option><option value='Samoan' >Samoan</option><option value='Sao Tomean' >Sao Tomean</option><option value='Saudi Arabian' >Saudi Arabian</option><option value='Scottish' >Scottish</option><option value='Senegalese' >Senegalese</option><option value='Serbian' >Serbian</option><option value='Sierra Leonean' >Sierra Leonean</option><option value='Singaporean' >Singaporean</option><option value='Slovak' >Slovak</option><option value='Slovenian' >Slovenian</option><option value='Solomon Islander' >Solomon Islander</option><option value='Somali' >Somali</option><option value='South African' >South African</option><option value='South Korean' >South Korean</option><option value='South Sudanese' >South Sudanese</option><option value='Spanish' >Spanish</option><option value='Sri Lankan' >Sri Lankan</option><option value='Stateless' >Stateless</option><option value='St Helenian' >St Helenian</option><option value='St Lucian' >St Lucian</option><option value='Sudanese' >Sudanese</option><option value='Surinamese' >Surinamese</option><option value='Swazi' >Swazi</option><option value='Swedish' >Swedish</option><option value='Swiss' >Swiss</option><option value='Syrian' >Syrian</option><option value='Taiwanese' >Taiwanese</option><option value='Tajik' >Tajik</option><option value='Tanzanian' >Tanzanian</option><option value='Thai' >Thai</option><option value='Togolese' >Togolese</option><option value='Tongan' >Tongan</option><option value='Trinidadian' >Trinidadian</option><option value='Tristanian' >Tristanian</option><option value='Tunisian' >Tunisian</option><option value='Turkish' >Turkish</option><option value='Turkmen' >Turkmen</option><option value='Turks and Caicos Islander' >Turks and Caicos Islander</option><option value='Tuvaluan' >Tuvaluan</option><option value='Ugandan' >Ugandan</option><option value='Ukrainian' >Ukrainian</option><option value='Uruguayan' >Uruguayan</option><option value='Uzbek' >Uzbek</option><option value='Vatican citizen' >Vatican citizen</option><option value='Venezuelan' >Venezuelan</option><option value='Vietnamese' >Vietnamese</option><option value='Vincentian' >Vincentian</option><option value='Wallisian' >Wallisian</option><option value='Welsh' >Welsh</option><option value='Yemeni' >Yemeni</option><option value='Zambian' >Zambian</option><option value='Zimbabwean' >Zimbabwean</option></select></div></li><li id="field_21_30" class="gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_30" ><label class='gfield_label gform-field-label' for='input_21_30'>Child or Young Person Ethnicity</label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_21_30' class='medium gfield_select' aria-invalid="false" ><option value='- Select -' >- Select -</option><option value='White British' >White British</option><option value='White Irish' >White Irish</option><option value='White other' >White other</option><option value='Caribbean' >Caribbean</option><option value='White and black Caribbean' >White and black Caribbean</option><option value='African' >African</option><option value='White and black African' >White and black African</option><option value='Black other' >Black other</option><option value='Indian' >Indian</option><option value='Pakistani' >Pakistani</option><option value='Bangladeshi' >Bangladeshi</option><option value='White and Asian' >White and Asian</option><option value='Asian other' >Asian other</option><option value='Chinese' >Chinese</option><option value='Any other mixed background' >Any other mixed background</option><option value='Other' >Other</option></select></div></li><li id="field_21_31" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_21_31" ><label class='gfield_label gform-field-label screen-reader-text' for='input_21_31'>Please specify</label><div class='gfield_description' id='gfield_description_21_31'>Please specify</div><div class='ginput_container ginput_container_text'><input name='input_31' id='input_21_31' type='text' value='' class='small' aria-describedby="gfield_description_21_31" aria-invalid="false" /></div></li><li id="field_21_32" class="gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_32" ><label class='gfield_label gform-field-label' for='input_21_32'>Child or Young Person Religion</label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_21_32' class='medium gfield_select' aria-invalid="false" ><option value='- Select -' >- Select -</option><option value='Buddhist' >Buddhist</option><option value='Christianity' >Christianity</option><option value='Hindu' >Hindu</option><option value='Jewish' >Jewish</option><option value='Muslim' >Muslim</option><option value='Sikh' >Sikh</option><option value='None' >None</option><option value='Other' >Other</option></select></div></li><li id="field_21_33" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_21_33" ><label class='gfield_label gform-field-label screen-reader-text' for='input_21_33'>Please specify</label><div class='gfield_description' id='gfield_description_21_33'>Please specify</div><div class='ginput_container ginput_container_text'><input name='input_33' id='input_21_33' type='text' value='' class='small' aria-describedby="gfield_description_21_33" aria-invalid="false" /></div></li><li id="field_21_35" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_35" ><h2>Young person's diagnosis</h2> <br> To process your application and ensure eligibility, it is necessary for us to use information about your/your child's health. By providing this information, you are agreeing for us to use it for these purposes. </li><li id="field_21_67" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_67" ><label class='gfield_label gform-field-label' for='input_21_67'>Your hospital name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_select'><select name='input_67' id='input_21_67' class='medium gfield_select' aria-required="true" aria-invalid="false" ><option value='- Select -' >- Select -</option><option value='Aberdeen Royal Infirmary' >Aberdeen Royal Infirmary</option><option value='Bedford Hospital' >Bedford Hospital</option><option value='Borders General Hospital' >Borders General Hospital</option><option value='Cheltenham General Hospital' >Cheltenham General Hospital</option><option value='City Hospital, Birmingham' >City Hospital, Birmingham</option><option value='County Hospital Stafford' >County Hospital Stafford</option><option value='Diana Princess of Wales Hospital' >Diana Princess of Wales Hospital</option><option value='Downe Hospital' >Downe Hospital</option><option value='Forth Valley Royal Hospital' >Forth Valley Royal Hospital</option><option value='Glasgow Royal Infirmary' >Glasgow Royal Infirmary</option><option value='Good Hope Hospital' >Good Hope Hospital</option><option value='Grantham & District Hospital' >Grantham & District Hospital</option><option value='Guernsey Hospital' >Guernsey Hospital</option><option value='Guy's Hospital' >Guy's Hospital</option><option value='Hammersmith Hospital' >Hammersmith Hospital</option><option value='Heartlands Hospital - Birmingham' >Heartlands Hospital - Birmingham</option><option value='Hinchingbrooke Hospital' >Hinchingbrooke Hospital</option><option value='James Paget Hospital, Great Yarmouth' >James Paget Hospital, Great Yarmouth</option><option value='King Edward Hospital' >King Edward Hospital</option><option value='Kings Mill Hospital' >Kings Mill Hospital</option><option value='Mount Vernon Hospital' >Mount Vernon Hospital</option><option value='New Victoria Hospital Glasgow' >New Victoria Hospital Glasgow</option><option value='Perth Royal Infirmary' >Perth Royal Infirmary</option><option value='Pilgrim Hospital - Boston' >Pilgrim Hospital - Boston</option><option value='Queen Charlotte's & Chelsea' >Queen Charlotte's & Chelsea</option><option value='Royal Albert Edward Infirmary' >Royal Albert Edward Infirmary</option><option value='Royal Alexandra Hospital - Paisley' >Royal Alexandra Hospital - Paisley</option><option value='Royal Derby Hospital' >Royal Derby Hospital</option><option value='Royal Hallamshire Hospital' >Royal Hallamshire Hospital</option><option value='Royal Marsden London' >Royal Marsden London</option><option value='Royal Orthopaedic Hospital, Birmingham' >Royal Orthopaedic Hospital, Birmingham</option><option value='Royal Shrewsbury Hospital' >Royal Shrewsbury Hospital</option><option value='Royal Victoria Hospital Belfast' >Royal Victoria Hospital Belfast</option><option value='Russells Hall' >Russells Hall</option><option value='Sandwell General Hospital' >Sandwell General Hospital</option><option value='Southmead Hospital' >Southmead Hospital</option><option value='St. George's - Tooting' >St. George's - Tooting</option><option value='St John's Hospital, West Lothian' >St John's Hospital, West Lothian</option><option value='St Mary's Hospital' >St Mary's Hospital</option><option value='Stoke Mandeville Hospital' >Stoke Mandeville Hospital</option><option value='Sunderland Royal Hospital' >Sunderland Royal Hospital</option><option value='Tyrone & Fermanagh Hospital' >Tyrone & Fermanagh Hospital</option><option value='Ulster Hospital' >Ulster Hospital</option><option value='Victoria Hospital - Kirkcaldy Fife' >Victoria Hospital - Kirkcaldy Fife</option><option value='Leicester Royal Infirmary Hospital' >Leicester Royal Infirmary Hospital</option><option value='Barts ECMC (Barts Cancer Institute)' >Barts ECMC (Barts Cancer Institute)</option><option value='Belfast ECMC (Centre for Cancer Research and Cell Biology, Queen's University Belfast)' >Belfast ECMC (Centre for Cancer Research and Cell Biology, Queen's University Belfast)</option><option value='Edinburgh ECMC (Cancer Research Centre, University of Edinburgh)' >Edinburgh ECMC (Cancer Research Centre, University of Edinburgh)</option><option value='Imperial College London ECMC' >Imperial College London ECMC</option><option value='King's Health Partners ECMC (KCH and Guy's & St. Thomas')' >King's Health Partners ECMC (KCH and Guy's & St. Thomas')</option><option value='Leicester ECMC (Department of Cancer Studies, University of Leicester)' >Leicester ECMC (Department of Cancer Studies, University of Leicester)</option><option value='Liverpool ECMC (Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool)' >Liverpool ECMC (Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool)</option><option value='London Institute of Cancer Research ECMC' >London Institute of Cancer Research ECMC</option><option value='Oxford ECMC (University of Oxford)' >Oxford ECMC (University of Oxford)</option><option value='Spire Parkway Hospital' >Spire Parkway Hospital</option><option value='Barnet Hospital' >Barnet Hospital</option><option value='Basildon University Hospital' >Basildon University Hospital</option><option value='Basingstoke and North Hampshire Hospital' >Basingstoke and North Hampshire Hospital</option><option value='Blackpool Victoria Hospital' >Blackpool Victoria Hospital</option><option value='Bristol Royal Infirmary' >Bristol Royal Infirmary</option><option value='Broomfield Hospital' >Broomfield Hospital</option><option value='Castle Hill Hospital' >Castle Hill Hospital</option><option value='Charing Cross Hospital' >Charing Cross Hospital</option><option value='Chelsea & Westminster Hospital' >Chelsea & Westminster Hospital</option><option value='Colchester General Hospital' >Colchester General Hospital</option><option value='Conquest Hospital' >Conquest Hospital</option><option value='Countess of Chester Hospital' >Countess of Chester Hospital</option><option value='Croydon University Hospital' >Croydon University Hospital</option><option value='Derriford Hospital - Plymouth' >Derriford Hospital - Plymouth</option><option value='Dorset County Hospital' >Dorset County Hospital</option><option value='East Surrey Hospital' >East Surrey Hospital</option><option value='Epsom Hospital' >Epsom Hospital</option><option value='Frimley Park Hospital' >Frimley Park Hospital</option><option value='Glan Clwyd Hospital (Ysbyty Glan Clwyd)' >Glan Clwyd Hospital (Ysbyty Glan Clwyd)</option><option value='Gloucestershire Royal Hospital' >Gloucestershire Royal Hospital</option><option value='Great Western Hospital - Swindon' >Great Western Hospital - Swindon</option><option value='Hull Royal Infirmary' >Hull Royal Infirmary</option><option value='Ipswich Hospital' >Ipswich Hospital</option><option value='Jersey General Hospital' >Jersey General Hospital</option><option value='Kent and Canterbury Hospital' >Kent and Canterbury Hospital</option><option value='Kettering General Hospital' >Kettering General Hospital</option><option value='Kings College Hospital' >Kings College Hospital</option><option value='Kingston Hospital' >Kingston Hospital</option><option value='Lincoln County Hospital' >Lincoln County Hospital</option><option value='Lister Hospital, Stevenage' >Lister Hospital, Stevenage</option><option value='Luton & Dunstable Hospital' >Luton & Dunstable Hospital</option><option value='Maidstone Hospital' >Maidstone Hospital</option><option value='Medway Maritime Hospital' >Medway Maritime Hospital</option><option value='Milton Keynes Hospital' >Milton Keynes Hospital</option><option value='Musgrove Park Hospital' >Musgrove Park Hospital</option><option value='Nevill Hall Hospital Abergavenny' >Nevill Hall Hospital Abergavenny</option><option value='New Cross Hospital - Wolverhampton' >New Cross Hospital - Wolverhampton</option><option value='Newham University Hospital' >Newham University Hospital</option><option value='Ninewells Hospital - Dundee' >Ninewells Hospital - Dundee</option><option value='Norfolk & Norwich University Hospital' >Norfolk & Norwich University Hospital</option><option value='Northampton General Hospital' >Northampton General Hospital</option><option value='North Devon District Hospital' >North Devon District Hospital</option><option value='North Wales Cancer Treatment Centre, Glan Clwyd Hospital' >North Wales Cancer Treatment Centre, Glan Clwyd Hospital</option><option value='Northwick Park Hospital' >Northwick Park Hospital</option><option value='Our Lady's Children's Hospital, Dublin' >Our Lady's Children's Hospital, Dublin</option><option value='Peterborough City Hospital' >Peterborough City Hospital</option><option value='Poole Hosptial' >Poole Hosptial</option><option value='Prince Charles Hospital' >Prince Charles Hospital</option><option value='Princess Alexandra Hospital, Harlow' >Princess Alexandra Hospital, Harlow</option><option value='Princess Royal Hospital' >Princess Royal Hospital</option><option value='Princess Royal Hospital Telford' >Princess Royal Hospital Telford</option><option value='Princess Royal University Hospital' >Princess Royal University Hospital</option><option value='Queen Alexandra Hospital' >Queen Alexandra Hospital</option><option value='Queen Elizabeth Hospital, Kings Lynn' >Queen Elizabeth Hospital, Kings Lynn</option><option value='Queen Elizabeth Hospital Woolwich' >Queen Elizabeth Hospital Woolwich</option><option value='Queen's Hospital' >Queen's Hospital</option><option value='Queens Hospital Romford' >Queens Hospital Romford</option><option value='Raigmore Hospital - Inverness' >Raigmore Hospital - Inverness</option><option value='Royal Berkshire Hospital - Reading' >Royal Berkshire Hospital - Reading</option><option value='Royal Bournemouth General Hospital' >Royal Bournemouth General Hospital</option><option value='Royal Cornwall Hospital (Treliske)' >Royal Cornwall Hospital (Treliske)</option><option value='Royal Devon and Exeter - Hospital (Wonford)' >Royal Devon and Exeter - Hospital (Wonford)</option><option value='Royal Free Hospital' >Royal Free Hospital</option><option value='Royal Hampshire County Hospital' >Royal Hampshire County Hospital</option><option value='Royal London Hospital' >Royal London Hospital</option><option value='Royal Preston Hospital' >Royal Preston Hospital</option><option value='Royal Stoke University Hospital' >Royal Stoke University Hospital</option><option value='Royal Surrey County Hospital' >Royal Surrey County Hospital</option><option value='Royal United Hospital - Bath' >Royal United Hospital - Bath</option><option value='Salisbury District Hospital' >Salisbury District Hospital</option><option value='Scarborough General Hospital' >Scarborough General Hospital</option><option value='Singleton Hospital (Swansea)' >Singleton Hospital (Swansea)</option><option value='Southend University Hospital' >Southend University Hospital</option><option value='Southport & Ormskirk District General Hospital' >Southport & Ormskirk District General Hospital</option><option value='St Bartholomew's Hospital' >St Bartholomew's Hospital</option><option value='St George's Hospital' >St George's Hospital</option><option value='St John's Hospital, Chelmsford' >St John's Hospital, Chelmsford</option><option value='St Mary's Hospital - Isle of Wight' >St Mary's Hospital - Isle of Wight</option><option value='St Mary's Hospital - Portsmouth' >St Mary's Hospital - Portsmouth</option><option value='St Peter's Hospital' >St Peter's Hospital</option><option value='St Richard's Hospital' >St Richard's Hospital</option><option value='St Thomas' Hospital' >St Thomas' Hospital</option><option value='The County Hospital' >The County Hospital</option><option value='THE WHITTINGTON HOSPITAL' >THE WHITTINGTON HOSPITAL</option><option value='The York Hospital' >The York Hospital</option><option value='Tunbridge Wells Hospitral' >Tunbridge Wells Hospitral</option><option value='University Hospital Coventry' >University Hospital Coventry</option><option value='University Hospital Lewisham' >University Hospital Lewisham</option><option value='Watford General Hospital' >Watford General Hospital</option><option value='West Suffolk Hospital' >West Suffolk Hospital</option><option value='Wexham Park Hospital' >Wexham Park Hospital</option><option value='Worcester Royal Hospital' >Worcester Royal Hospital</option><option value='Worthing Hospital' >Worthing Hospital</option><option value='Wrexham Maelor Hospital' >Wrexham Maelor Hospital</option><option value='Yeovil District Hospital' >Yeovil District Hospital</option><option value='Ysbyty Gwynedd Hospital - Bangor' >Ysbyty Gwynedd Hospital - Bangor</option><option value='Alder Hey Children's Hospital' >Alder Hey Children's Hospital</option><option value='Bristol Hospital for Sick Children' >Bristol Hospital for Sick Children</option><option value='Great North Children's Hospital (Royal Victoria Infirmary)' >Great North Children's Hospital (Royal Victoria Infirmary)</option><option value='Great Ormond Street Hospital for Sick Children' >Great Ormond Street Hospital for Sick Children</option><option value='John Radcliffe - Oxford' >John Radcliffe - Oxford</option><option value='Leeds Children's Hospital' >Leeds Children's Hospital</option><option value='Noah's Ark Children's Hospital' >Noah's Ark Children's Hospital</option><option value='Royal Aberdeen Childrens Hospital' >Royal Aberdeen Childrens Hospital</option><option value='Royal Belfast Hospital for Sick Children' >Royal Belfast Hospital for Sick Children</option><option value='Royal Children's Hospital Glasgow' >Royal Children's Hospital Glasgow</option><option value='ROYAL HOSPITAL FOR SICK CHILDREN EDINBURGH' >ROYAL HOSPITAL FOR SICK CHILDREN EDINBURGH</option><option value='Royal Manchester Children's Hospital' >Royal Manchester Children's Hospital</option><option value='Addenbrooke's Hospital' >Addenbrooke's Hospital</option><option value='Birmingham Children's Hospital' >Birmingham Children's Hospital</option><option value='Royal Marsden - Sutton' >Royal Marsden - Sutton</option><option value='Sheffield Children's Hospital' >Sheffield Children's Hospital</option><option value='Southampton General Hospital' >Southampton General Hospital</option><option value='University College London Hospital' >University College London Hospital</option><option value='University Hospital Wales' >University Hospital Wales</option><option value='Nottingham Children's Hospital (Queen's Medical Centre)' >Nottingham Children's Hospital (Queen's Medical Centre)</option><option value='Royal Alexandra Children's Hospital - Brighton' >Royal Alexandra Children's Hospital - Brighton</option><option value='Beatson Cancer Centre - Glasgow' >Beatson Cancer Centre - Glasgow</option><option value='Belfast City Hospital & NI Cancer Centre' >Belfast City Hospital & NI Cancer Centre</option><option value='Bristol Haematology and Oncology Centre' >Bristol Haematology and Oncology Centre</option><option value='Christie Hospital Manchester' >Christie Hospital Manchester</option><option value='Churchill Hospital - Oxford' >Churchill Hospital - Oxford</option><option value='Clatterbridge Centre for Oncology - Wirral' >Clatterbridge Centre for Oncology - Wirral</option><option value='Freeman Hospital' >Freeman Hospital</option><option value='Nottingham City Hospital' >Nottingham City Hospital</option><option value='Queen Elizabeth Hospital Birmingham' >Queen Elizabeth Hospital Birmingham</option><option value='St. James's University Hospital - Leeds' >St. James's University Hospital - Leeds</option><option value='Western General Hospital - Edinburgh' >Western General Hospital - Edinburgh</option><option value='Weston Park, Sheffield' >Weston Park, Sheffield</option><option value='Other' >Other</option></select></div></li><li id="field_21_72" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_21_72" ><label class='gfield_label gform-field-label screen-reader-text' for='input_21_72'>Please specify<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='gfield_description' id='gfield_description_21_72'><p>Please specify</p> </div><div class='ginput_container ginput_container_text'><input name='input_72' id='input_21_72' type='text' value='' class='medium' aria-describedby="gfield_description_21_72" aria-required="true" aria-invalid="false" /></div></li><li id="field_21_40" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_40" ><label class='gfield_label gform-field-label' for='input_21_40'>What was the date of your diagnosis?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_date'> <input aria-describedby='field_21_40_dmessage' name='input_40' id='input_21_40' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon' placeholder='dd/mm/yyyy' aria-describedby="input_21_40_date_format" aria-invalid="false" aria-required="true"/> <span id='input_21_40_date_format' class='screen-reader-text'>DD slash MM slash YYYY</span> </div> <input type='hidden' id='gforms_calendar_icon_input_21_40' class='gform_hidden' value='https://www.younglivesvscancer.org.uk/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg'/></li><li id="field_21_70" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_70" ><label class='gfield_label gform-field-label' for='input_21_70'>Please tell us what your cancer diagnosis is.<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_select'><select name='input_70' id='input_21_70' class='medium gfield_select' aria-required="true" aria-invalid="false" ><option value='- Select -' >- Select -</option><option value='Acute lymphoblastic leukaemia (ALL)' >Acute lymphoblastic leukaemia (ALL)</option><option value='Acute myeloid leukaemia (AML)' >Acute myeloid leukaemia (AML)</option><option value='Adrenal gland tumours' >Adrenal gland tumours</option><option value='Anal cancer' >Anal cancer</option><option value='Angiosarcoma' >Angiosarcoma</option><option value='Astrocytoma' >Astrocytoma</option><option value='Bile duct cancer' >Bile duct cancer</option><option value='Bladder cancer' >Bladder cancer</option><option value='Bone cancer' >Bone cancer</option><option value='Bowel cancer' >Bowel cancer</option><option value='Brain and CNS' >Brain and CNS</option><option value='Breast cancer' >Breast cancer</option><option value='Cancer of unknown primary (CUP)' >Cancer of unknown primary (CUP)</option><option value='Carcinoid' >Carcinoid</option><option value='Cervical cancer' >Cervical cancer</option><option value='Chronic lymphocytic leukaemia (CLL)' >Chronic lymphocytic leukaemia (CLL)</option><option value='Chronic myeloid leukaemia (CML)' >Chronic myeloid leukaemia (CML)</option><option value='Colorectal cancer' >Colorectal cancer</option><option value='Craniopharyngeoma' >Craniopharyngeoma</option><option value='Ear cancer' >Ear cancer</option><option value='Endometrial cancer' >Endometrial cancer</option><option value='Ependymoma' >Ependymoma</option><option value='Epithelial' >Epithelial</option><option value='Ewings Sarcoma' >Ewings Sarcoma</option><option value='Eye cancer' >Eye cancer</option><option value='Fibroblastic Sarcoma' >Fibroblastic Sarcoma</option><option value='Follicular dendritic cell sarcoma' >Follicular dendritic cell sarcoma</option><option value='Gallbladder cancer' >Gallbladder cancer</option><option value='Gastric cancer' >Gastric cancer</option><option value='Gastro-Intestinal Stromal Tumour (GIST)' >Gastro-Intestinal Stromal Tumour (GIST)</option><option value='Gastro oesophageal junction cancers' >Gastro oesophageal junction cancers</option><option value='Germ cell tumours' >Germ cell tumours</option><option value='Gestational trophoblastic disease (GTD)' >Gestational trophoblastic disease (GTD)</option><option value='Glioma' >Glioma</option><option value='Haemangioblastoma' >Haemangioblastoma</option><option value='Haemangioendothelioma' >Haemangioendothelioma</option><option value='Haemangiosarcoma' >Haemangiosarcoma</option><option value='Hairy cell leukaemia' >Hairy cell leukaemia</option><option value='Hepatic' >Hepatic</option><option value='Head and neck cancer' >Head and neck cancer</option><option value='Hepatobastoma' >Hepatobastoma</option><option value='Heptacellular Carcinoma' >Heptacellular Carcinoma</option><option value='Hodgkin lymphoma' >Hodgkin lymphoma</option><option value='Kaposi’s sarcoma' >Kaposi’s sarcoma</option><option value='Kidney cancer' >Kidney cancer</option><option value='Laryngeal cancer' >Laryngeal cancer</option><option value='Leiomyosarcoma' >Leiomyosarcoma</option><option value='Leukaemia' >Leukaemia</option><option value='Linitis plastica of the stomach' >Linitis plastica of the stomach</option><option value='Liposarcoma' >Liposarcoma</option><option value='Liver cancer' >Liver cancer</option><option value='Lung cancer' >Lung cancer</option><option value='Lymphangiosarcoma' >Lymphangiosarcoma</option><option value='Lymphoma' >Lymphoma</option><option value='Malignant Peripheral Nerve Sheath Tumour (MPNST)' >Malignant Peripheral Nerve Sheath Tumour (MPNST)</option><option value='Malignant schwannoma' >Malignant schwannoma</option><option value='Mediastinal germ cell tumours' >Mediastinal germ cell tumours</option><option value='Melanoma skin cancer' >Melanoma skin cancer</option><option value='Meningioma' >Meningioma</option><option value='Merkel cell skin cancer' >Merkel cell skin cancer</option><option value='Mesothelioma' >Mesothelioma</option><option value='Molar pregnancy' >Molar pregnancy</option><option value='Mouth and oropharyngeal cancer' >Mouth and oropharyngeal cancer</option><option value='Myeloma' >Myeloma</option><option value='Nasal and paranasal sinus cancer' >Nasal and paranasal sinus cancer</option><option value='Nasopharyngeal cancer' >Nasopharyngeal cancer</option><option value='Neuroblastoma' >Neuroblastoma</option><option value='Neuroendocrine tumours' >Neuroendocrine tumours</option><option value='neurofibrosarcoma' >neurofibrosarcoma</option><option value='Non-Hodgkin lymphoma (NHL)' >Non-Hodgkin lymphoma (NHL)</option><option value='Non-Wilm's Tumour' >Non-Wilm's Tumour</option><option value='Not Set' >Not Set</option><option value='Oesophageal cancer' >Oesophageal cancer</option><option value='Oligodendroglioma' >Oligodendroglioma</option><option value='Oral' >Oral</option><option value='Osteosarcoma' >Osteosarcoma</option><option value='Other' >Other</option><option value='Ovarian cancer' >Ovarian cancer</option><option value='Pancreatic cancer' >Pancreatic cancer</option><option value='Penile cancer' >Penile cancer</option><option value='Persistent trophoblastic disease and choriocarcinoma' >Persistent trophoblastic disease and choriocarcinoma</option><option value='Phaeochromocytoma' >Phaeochromocytoma</option><option value='Pineal Tumour' >Pineal Tumour</option><option value='Pituitary Tumour' >Pituitary Tumour</option><option value='Primitive Neuroectodermal Tumour (PNET)' >Primitive Neuroectodermal Tumour (PNET)</option><option value='Prostate cancer' >Prostate cancer</option><option value='Pseudomyxoma peritonei' >Pseudomyxoma peritonei</option><option value='Rectal cancer' >Rectal cancer</option><option value='Retinoblastoma' >Retinoblastoma</option><option value='Rhabdomyosarcoma' >Rhabdomyosarcoma</option><option value='Salivary gland cancer' >Salivary gland cancer</option><option value='Schwannoma' >Schwannoma</option><option value='Signet cell cancer' >Signet cell cancer</option><option value='Skin cancer' >Skin cancer</option><option value='Small bowel cancer' >Small bowel cancer</option><option value='Soft tissue sarcoma' >Soft tissue sarcoma</option><option value='Spinal Cord Tumour' >Spinal Cord Tumour</option><option value='Stomach cancer' >Stomach cancer</option><option value='Synovial Sarcoma' >Synovial Sarcoma</option><option value='T cell childhood non Hodgkin lymphoma (NHL)' >T cell childhood non Hodgkin lymphoma (NHL)</option><option value='Testicular cancer' >Testicular cancer</option><option value='Thymus gland cancer' >Thymus gland cancer</option><option value='Thyroid cancer' >Thyroid cancer</option><option value='Tongue cancer' >Tongue cancer</option><option value='Tonsil cancer' >Tonsil cancer</option><option value='Tumours of the adrenal gland' >Tumours of the adrenal gland</option><option value='Uterine cancer' >Uterine cancer</option><option value='Vaginal cancer' >Vaginal cancer</option><option value='Vascular Sarcoma' >Vascular Sarcoma</option><option value='Vestibular Schwannoma' >Vestibular Schwannoma</option><option value='Vulval cancer' >Vulval cancer</option><option value='Wilms' tumour' >Wilms' tumour</option><option value='Other' >Other</option></select></div></li><li id="field_21_71" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_21_71" ><label class='gfield_label gform-field-label screen-reader-text' for='input_21_71'>Please Specify<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='gfield_description' id='gfield_description_21_71'><p>Please Specify</p> </div><div class='ginput_container ginput_container_text'><input name='input_71' id='input_21_71' type='text' value='' class='medium' aria-describedby="gfield_description_21_71" aria-required="true" aria-invalid="false" /></div></li><li id="field_21_101" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_101" ><label class='gfield_label gform-field-label' >Is this a relapse/secondary cancer diagnosis?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_101'> <li class='gchoice gchoice_21_101_0'> <input name='input_101' type='radio' value='Yes' id='choice_21_101_0' /> <label for='choice_21_101_0' id='label_21_101_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </li> <li class='gchoice gchoice_21_101_1'> <input name='input_101' type='radio' value='No' id='choice_21_101_1' /> <label for='choice_21_101_1' id='label_21_101_1' class='gform-field-label gform-field-label--type-inline'>No</label> </li></ul></div></fieldset></li><li id="field_21_102" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_102" ><label class='gfield_label gform-field-label' >Relapse only: I confirm that my child/I<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_102'> <li class='gchoice gchoice_21_102_0'> <input name='input_102' type='radio' value='Received the diagnosis 12 or more months following the end of my previous treatment' id='choice_21_102_0' /> <label for='choice_21_102_0' id='label_21_102_0' class='gform-field-label gform-field-label--type-inline'>Received the diagnosis 12 or more months following the end of my previous treatment</label> </li></ul></div></fieldset></li><li id="field_21_36" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_36" ><h2>Your Details</h2> </li><li id="field_21_103" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_103" ><label class='gfield_label gform-field-label' for='input_21_103'>Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_21_103' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_104" class="gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_104" ><label class='gfield_label gform-field-label' for='input_21_104'>Relationship to young person<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_select'><select name='input_104' id='input_21_104' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='Select' >Select</option><option value='Parent/carer' >Parent/carer</option><option value='Partner' >Partner</option><option value='Family member' >Family member</option><option value='Other' >Other</option></select></div></li><li id="field_21_105" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_105" ><label class='gfield_label gform-field-label' for='input_21_105'>Please specify:<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_21_105' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_6" class="gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_6" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip has_country ginput_container_address gform-grid-row' id='input_21_6' > <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_6_1_container' > <label for='input_21_6_1' id='input_21_6_1_label' class='gform-field-label gform-field-label--type-sub '>Address Line 1</label> <input type='text' name='input_6.1' id='input_21_6_1' value='' aria-required='true' /> </span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_21_6_2_container' > <label for='input_21_6_2' id='input_21_6_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2</label> <input type='text' name='input_6.2' id='input_21_6_2' value='' aria-required='false' /> </span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_6_3_container' > <label for='input_21_6_3' id='input_21_6_3_label' class='gform-field-label gform-field-label--type-sub '>Town/City</label> <input type='text' name='input_6.3' id='input_21_6_3' value='' aria-required='true' /> </span><input type='hidden' class='gform_hidden' name='input_6.4' id='input_21_6_4' value=''/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_21_6_5_container' > <label for='input_21_6_5' id='input_21_6_5_label' class='gform-field-label gform-field-label--type-sub '>Postcode</label> <input type='text' name='input_6.5' id='input_21_6_5' value='' aria-required='true' /> </span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_21_6_6_container' > <label for='input_21_6_6' id='input_21_6_6_label' class='gform-field-label gform-field-label--type-sub '>Country</label> <select name='input_6.6' id='input_21_6_6' aria-required='true' ><option value='' ></option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czechia' >Czechia</option><option value='Côte d'Ivoire' >Côte d'Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini' >Eswatini</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Korea, Democratic People's Republic of' >Korea, Democratic People's Republic of</option><option value='Korea, Republic of' >Korea, Republic of</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People's Democratic Republic' >Lao People's Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macao' >Macao</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Macedonia' >North Macedonia</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russian Federation' >Russian Federation</option><option value='Rwanda' >Rwanda</option><option value='Réunion' >Réunion</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria Arab Republic' >Syria Arab Republic</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='Türkiye' >Türkiye</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' selected='selected'>United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Viet Nam' >Viet Nam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='Åland Islands' >Åland Islands</option> </select> </span> <div class='gf_clear gf_clear_complex'></div> </div></fieldset></li><li id="field_21_8" class="gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_8" ><label class='gfield_label gform-field-label' for='input_21_8'>Telephone Number<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_21_8' type='tel' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_4" class="gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_4" ><label class='gfield_label gform-field-label' for='input_21_4'>Email address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_email'> <input name='input_4' id='input_21_4' type='email' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_21_42" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_42" ><h2>Your grant request details</h2> </li><li id="field_21_68" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_68" ><label class='gfield_label gform-field-label' for='input_21_68'>Please tell us what your grant will be used for.<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_select'><select name='input_68' id='input_21_68' class='medium gfield_select' aria-required="true" aria-invalid="false" ><option value='- Select -' >- Select -</option><option value='Accommodation' >Accommodation</option><option value='Clothing' >Clothing</option><option value='Family days out' >Family days out</option><option value='Food' >Food</option><option value='Heating costs' >Heating costs</option><option value='Holiday' >Holiday</option><option value='Home help and childcare' >Home help and childcare</option><option value='Home improvement and furniture' >Home improvement and furniture</option><option value='Hospital Parking' >Hospital Parking</option><option value='Household bills' >Household bills</option><option value='Recovery equipment and services' >Recovery equipment and services</option><option value='Travel (not parking)' >Travel (not parking)</option><option value='' >Treats</option></select></div></li><li id="field_21_80" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_80" ><p>Our grants are paid by bank transfer (BACS), and to do this we need the following bank account details from you:</p> </li><li id="field_21_81" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_81" ><label class='gfield_label gform-field-label' for='input_21_81'>Account name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_21_81' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_83" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_83" ><label class='gfield_label gform-field-label' for='input_21_83'>Account number<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_21_83' type='text' value='' class='medium' maxlength='8' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_84" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_84" ><label class='gfield_label gform-field-label' for='input_21_84'>Sort Code<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_21_84' type='text' value='' class='medium' maxlength='6' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_47" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_47" ><h2>Details of verifier</h2> <p><font color="#000000"><font face="Segoe UI"><font size="2">Please provide contact details for your healthcare professional (e.g. your doctor or nurse) to enable us to verify your details.</font></font></font></p> </li><li id="field_21_48" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_48" ><label class='gfield_label gform-field-label' for='input_21_48'>Title<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_21_48' class='small gfield_select' aria-required="true" aria-invalid="false" ><option value='' >- Select -</option><option value='Dr' >Dr</option><option value='Miss' >Miss</option><option value='Mr' >Mr</option><option value='Mrs' >Mrs</option><option value='Ms' >Ms</option><option value='Other' >Other</option></select></div></li><li id="field_21_49" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_21_49" ><label class='gfield_label gform-field-label screen-reader-text' for='input_21_49'>Please specify</label><div class='gfield_description' id='gfield_description_21_49'>Please specify</div><div class='ginput_container ginput_container_text'><input name='input_49' id='input_21_49' type='text' value='' class='small' aria-describedby="gfield_description_21_49" aria-invalid="false" /></div></li><li id="field_21_50" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_50" ><label class='gfield_label gform-field-label' for='input_21_50'>First Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_21_50' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_51" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_51" ><label class='gfield_label gform-field-label' for='input_21_51'>Last Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_21_51' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_56" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_56" ><label class='gfield_label gform-field-label' for='input_21_56'>NHS e-mail address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_21_56' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_21_61" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_61" ><label class='gfield_label gform-field-label' >I give permission for Young Lives vs Cancer to contact the above named health care professional using the email address I have provided in order to verify information I have submitted on this application form.<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_61'> <li class='gchoice gchoice_21_61_0'> <input name='input_61' type='radio' value='Please check to confirm' id='choice_21_61_0' /> <label for='choice_21_61_0' id='label_21_61_0' class='gform-field-label gform-field-label--type-inline'>Please check to confirm</label> </li></ul></div></fieldset></li><li id="field_21_93" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_93" ><p>We reserve the right to withhold payment of this grant should we be unable to verify your details, and we will reclaim the grant if we later find that you do not meet the eligibility criteria detailed above.</p> </li><li id="field_21_94" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_94" ><label class='gfield_label gform-field-label gfield_label_before_complex' >How did you hear about this grant?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_21_94'><li class='gchoice gchoice_21_94_1'> <input class='gfield-choice-input' name='input_94.1' type='checkbox' value='Young Lives vs Cancer Care Professional' id='choice_21_94_1' /> <label for='choice_21_94_1' id='label_21_94_1' class='gform-field-label gform-field-label--type-inline'>Young Lives vs Cancer Care Professional</label> </li><li class='gchoice gchoice_21_94_2'> <input class='gfield-choice-input' name='input_94.2' type='checkbox' value='Friend/family' id='choice_21_94_2' /> <label for='choice_21_94_2' id='label_21_94_2' class='gform-field-label gform-field-label--type-inline'>Friend/family</label> </li><li class='gchoice gchoice_21_94_3'> <input class='gfield-choice-input' name='input_94.3' type='checkbox' value='Internet Search' id='choice_21_94_3' /> <label for='choice_21_94_3' id='label_21_94_3' class='gform-field-label gform-field-label--type-inline'>Internet Search</label> </li><li class='gchoice gchoice_21_94_4'> <input class='gfield-choice-input' name='input_94.4' type='checkbox' value='NHS Professional' id='choice_21_94_4' /> <label for='choice_21_94_4' id='label_21_94_4' class='gform-field-label gform-field-label--type-inline'>NHS Professional</label> </li><li class='gchoice gchoice_21_94_5'> <input class='gfield-choice-input' name='input_94.5' type='checkbox' value='Another charity' id='choice_21_94_5' /> <label for='choice_21_94_5' id='label_21_94_5' class='gform-field-label gform-field-label--type-inline'>Another charity</label> </li><li class='gchoice gchoice_21_94_6'> <input class='gfield-choice-input' name='input_94.6' type='checkbox' value='Other professionals' id='choice_21_94_6' /> <label for='choice_21_94_6' id='label_21_94_6' class='gform-field-label gform-field-label--type-inline'>Other professionals</label> </li><li class='gchoice gchoice_21_94_7'> <input class='gfield-choice-input' name='input_94.7' type='checkbox' value='Promotional materials in the community (GP, University etc)' id='choice_21_94_7' /> <label for='choice_21_94_7' id='label_21_94_7' class='gform-field-label gform-field-label--type-inline'>Promotional materials in the community (GP, University etc)</label> </li><li class='gchoice gchoice_21_94_8'> <input class='gfield-choice-input' name='input_94.8' type='checkbox' value='Social media' id='choice_21_94_8' /> <label for='choice_21_94_8' id='label_21_94_8' class='gform-field-label gform-field-label--type-inline'>Social media</label> </li><li class='gchoice gchoice_21_94_9'> <input class='gfield-choice-input' name='input_94.9' type='checkbox' value='Other' id='choice_21_94_9' /> <label for='choice_21_94_9' id='label_21_94_9' class='gform-field-label gform-field-label--type-inline'>Other</label> </li></ul></div></fieldset></li><li id="field_21_77" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_21_77" ><label class='gfield_label gform-field-label screen-reader-text' for='input_21_77'>Please specify</label><div class='gfield_description' id='gfield_description_21_77'>Please specify</div><div class='ginput_container ginput_container_text'><input name='input_77' id='input_21_77' type='text' value='' class='small' aria-describedby="gfield_description_21_77" aria-invalid="false" /></div></li><li id="field_21_63" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_21_63" ><label class='gfield_label gform-field-label' >As well as financial support, Young Lives vs Cancer provides emotional and practical support to children and young people with cancer and their families. If you would like to find out more about how we might be able to help you, tick ‘yes’ and we’ll get in touch.<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='gfield_description' id='gfield_description_21_63'><div style="margin: 0cm 0cm 0pt;">I am happy for my details to be shared with Young Lives vs Cancer so they can get in touch with me about further help and support.  </div> </div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_63'> <li class='gchoice gchoice_21_63_0'> <input name='input_63' type='radio' value='Yes' id='choice_21_63_0' /> <label for='choice_21_63_0' id='label_21_63_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </li></ul></div></fieldset></li><li id="field_21_100" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_100" ><p>Please note that if your child is under 18 and being treated in South Wales (up to Aberystwyth) , we will assume you are being supported by LATCH which provides similar support to Young Lives vs Cancer. We won't contact you directly, but if you want to learn more about our services, you are very welcome to get in touch with us on 0300 303 5220 or email <a href = "mailto: getsupport@younglivesvscancer.org.uk">getsupport@younglivesvscancer.org.uk</a></p></li><li id="field_21_95" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_95" ><p>If you've ticked 'Yes' - how would you prefer us to get in touch with you?</p> </li><li id="field_21_96" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_96" ><label class='gfield_label gform-field-label' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_96'> <li class='gchoice gchoice_21_96_0'> <input name='input_96' type='radio' value='Yes' id='choice_21_96_0' /> <label for='choice_21_96_0' id='label_21_96_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </li> <li class='gchoice gchoice_21_96_1'> <input name='input_96' type='radio' value='No' id='choice_21_96_1' /> <label for='choice_21_96_1' id='label_21_96_1' class='gform-field-label gform-field-label--type-inline'>No</label> </li></ul></div></fieldset></li><li id="field_21_98" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_98" ><label class='gfield_label gform-field-label' >Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk"> * <span class='sr-only'> REQUIRED</span></span></span></label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_98'> <li class='gchoice gchoice_21_98_0'> <input name='input_98' type='radio' value='Yes' id='choice_21_98_0' /> <label for='choice_21_98_0' id='label_21_98_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </li> <li class='gchoice gchoice_21_98_1'> <input name='input_98' type='radio' value='No' id='choice_21_98_1' /> <label for='choice_21_98_1' id='label_21_98_1' class='gform-field-label gform-field-label--type-inline'>No</label> </li></ul></div></fieldset></li><li id="field_21_21" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_21" ><h2>Can we contact you about other things?</h2> <p>Without you, we can’t fight tirelessly for young lives against cancer. We want to let you know about the difference you make to young cancer patients and their families, and other opportunities you have to get involved with fundraising, volunteering and our campaigns. If you are happy to receive this information, please let us know how you would prefer to hear from us.</p> </li><li id="field_21_23" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_23" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Email</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_21_23'><li class='gchoice gchoice_21_23_1'> <input class='gfield-choice-input' name='input_23.1' type='checkbox' value='Yes' id='choice_21_23_1' /> <label for='choice_21_23_1' id='label_21_23_1' class='gform-field-label gform-field-label--type-inline'>Yes</label> </li></ul></div></fieldset></li><li id="field_21_26" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_26" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Text</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_21_26'><li class='gchoice gchoice_21_26_1'> <input class='gfield-choice-input' name='input_26.1' type='checkbox' value='Yes' id='choice_21_26_1' /> <label for='choice_21_26_1' id='label_21_26_1' class='gform-field-label gform-field-label--type-inline'>Yes</label> </li></ul></div></fieldset></li><li id="field_21_25" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_25" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Phone</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_21_25'><li class='gchoice gchoice_21_25_1'> <input class='gfield-choice-input' name='input_25.1' type='checkbox' value='Yes' id='choice_21_25_1' /> <label for='choice_21_25_1' id='label_21_25_1' class='gform-field-label gform-field-label--type-inline'>Yes</label> </li></ul></div></fieldset></li><li id="field_21_24" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_24" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Post</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_21_24'><li class='gchoice gchoice_21_24_1'> <input class='gfield-choice-input' name='input_24.1' type='checkbox' value='Yes' id='choice_21_24_1' /> <label for='choice_21_24_1' id='label_21_24_1' class='gform-field-label gform-field-label--type-inline'>Yes</label> </li></ul></div></fieldset></li><li id="field_21_22" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_22" ><p>Your details are safe with us. For more information about how Young Lives vs Cancer uses your information, please read our <a href="https://www.younglivesvscancer.org.uk/privacy-policy/">Services Privacy Notice</a>.</p> <p>You can update your preferences at any time by calling us on 0300 330 0803 or emailing <a href="mailto:supporter.services@younglivesvscancer.org.uk">supporter.services@younglivesvscancer.org.uk</a>. Our phone lines are open 9-5 Monday to Friday or you can contact us on Live Chat between 10-4 Monday to Friday.</p> <br> To process your application and eligibility for a grant, we will process the personal data that you have provided in this form. By submitting this application, you are confirming that you consent for us to use your/your child’s personal data for this purpose. If you receive a grant, we will maintain our records in accordance with our <a href="https://www.younglivesvscancer.org.uk/privacy-policy/">privacy policy</a> </li><li id="field_21_106" class="gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_106" ><label class='gfield_label gform-field-label' for='input_21_106'>Phone</label><div class='ginput_container'><input name='input_106' id='input_21_106' type='text' value='' autocomplete='new-password'/></div><div class='gfield_description' id='gfield_description_21_106'>This field is for validation purposes and should be left unchanged.</div></li></ul></div> <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_21' class='btn gform_button button' onclick='gform.submission.handleButtonClick(this)' value='Submit' /> <input type='hidden' name='gform_ajax' 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