"*" indicates required fields Step 1 of 5 20% Organisation name*Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Status*Registered CharityRegulated BodyOther (please specify)OtherRegistration no.Date your organisation/service was formed* DD slash MM slash YYYY Website*FacebookInstagramX (Previously Twitter)TikTokLinkedInPrimary contact (person completing this form)* First Last Email address* Phone number*Secondary contact* First Last Email address* Phone number*Communications Lead* First Last Email address* Phone number*Where did you hear about Lifelites 25? Website Google search AI search Social media Online advertisment Word of mouth Section 2 – Your mission, objectives and activitiesDescribe your organisation’s mission and objectives.*(Max 1,000 characters)Tell us about the people you support.*How old are they, what clinical and care needs do they have, what are their challenges (Max 1,000 characters)What is your track record of delivering services for children and young people with life-limiting conditions?*Tell us what services you provide, where you provide them and what impact they have had. (Max 1,000 characters)How many children with life-limiting conditions do you support on average per year?* Section 3 – Application for Lifelites supportTell us about the project or services that you are seeking support for.*Is it a new or existing service? Where, when, how often and during what services or activities you would use technology with children (Max 1,500 characters)How will you use this technology?*Tell us specifically how you would use technology to enhance your services, in what settings and how frequently - you might want to reference specific pieces of technology and talk about how you would use them (Max 1,000 characters)How many children with life-limiting conditions and complex needs do you expect to benefit?*How many children and young people do you expect to be supported in the following age ranges?0-56-1011-1818+How many staff/volunteers do you expect to use this technology?*What are the expected outcomes?*Tell us about the difference this will make to children, their families and your service and how will you measure this. (Max 1,000 characters) Section 4 – Assistive technology requestedWhen filling out your technology requests, please be aware that you can apply for up to £25,000 worth of technology. IMPORTANT - Please ensure you have closely consulted our Lifelites tech brochure before filling out this section of your application. This brochure provides detailed information about each piece of technology offered, including size and other technical specifications.Larger itemsListed below are a number of larger items that we can provide. Please carefully consider the number of items you request, your space requirements and the expected impact of each item of technology.Eyegaze Quantity Price: £ 5,300.00 Quantity Do you require a stand for your eyegaze? Rehadapt stand (floor stand) Portable clamp stand No Magic Carpet Quantity Price: £ 7,700.00 Quantity AV1 Robot Quantity Price: £ 7,000.00 Quantity Cost includes the robot and 4 year subscriptionTilt Table Quantity Price: £ 4,200.00 Quantity Soundbeam 6 Quantity Price: £ 3,600.00 Quantity GamingInteractive Entertainment Hub Quantity Price: £ 4,300.00 Quantity Cost is for full hub package - please select individual items as relevantHub items Select All Sony Playstation 5 XBox X Microsoft Adaptive Controller Additional XBox Controller Logitech Gaming Switch set Sony PS5 Adaptive Controller Games Package Meta Quest 3 & games Quantity Price: £ 650.00 Quantity PODs PlayPOD tent - Large Quantity Price: £ 1,200.00 Quantity POD tent - Small Quantity Price: £ 1,050.00 Quantity POD extra themes Quantity Price: £ 285.00 Quantity Extra PODs Themes Galactic Space Adventure Magical Princess Palace Polar Ice Igloo Rumble in the Jungle Sub Aqua Quest Sunset Safari Walking with Dinosaurs Please specify which extra theme(s) you would like.Portable TechnologyListed below are a number of smaller items that we can provide. Please carefully consider the number of items you request, your space/storage requirements and the expected impact of each item of technology.iPadsiPad with case and extras Quantity Price: £ 650.00 Quantity iPad charging (Large cabinet) Quantity Price: £ 900.00 Quantity iPad charging (Desktop) Quantity Price: £ 900.00 Quantity Will you require flexi arms? Yes No CameraaWildlife Window (max. cost) Quantity Price: £ 500.00 Quantity GoPro Camera Bundle Quantity Price: £ 450.00 Quantity Waterproof Camera Quantity Price: £ 215.00 Quantity SwitchesCosmo (6 switches) Quantity Price: £ 700.00 Quantity iClick Quantity Price: £ 250.00 Quantity Basic Switches Quantity Price: £ 150.00 Quantity Cost of each switch varies. Please select switch preferences from types.Switch types BigMac Recordable Switch Small Button Switch (for toys & iClick) Large Wireless Switch (for iClick) Candy Corn Proximity (for toys & iClick) Select which switches you requestSwitch Toy Quantity Price: £ 180.00 Quantity Cost includes toy and switchOddBalls Quantity Price: £ 100.00 Quantity Total We will fund up to a maximum of £25,000 technologyPlease let us know any other assistive technology you have identified and would like us to consider, including quantity and price Section 5 - Additional InformationPlease provide any further information you feel is relevant to this applicationPlease upload a copy of your children’s safeguarding policy (and vulnerable adults if applicable)*Max. file size: 64 MB.Please upload a copy of your most recent accounts*Max. file size: 64 MB.Please note successful applications will be subject to Lifelites' partnership agreement, which will set out the details of our services and our expectations in more detail.CommentsThis field is for validation purposes and should be left unchanged.