"*" indicates required fields Step 1 of 5 20% FacebookThis field is for validation purposes and should be left unchanged.Organisation name*Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican 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 RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussian FederationRwandaSaint 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 TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Status*Registered CharityRegulated BodyOther (please specify)OtherRegistration no.Date your organisation/service was formed* 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?*Please enter a number greater than or equal to 0. 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?*Please enter a number greater than or equal to 0.How many children and young people do you expect to be supported in the following age ranges?0-5Please enter a number greater than or equal to 0.6-10Please enter a number greater than or equal to 0.11-18Please enter a number greater than or equal to 0.18+Please enter a number greater than or equal to 0.How many staff/volunteers do you expect to use this technology?*Please enter a number greater than or equal to 0.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: £ 6,000.00 Quantity Do you require a stand for your eyegaze? Rehadapt stand (floor stand) Portable clamp stand No Magic Carpet Quantity Price: £ 7,900.00 Quantity Mini Magic Carpet Quantity Price: £ 4,850.00 Quantity AV1 Robot Quantity Price: £ 7,000.00 Quantity Cost includes the robot and 4 year subscriptionTilt Table Quantity Price: £ 4,500.00 Quantity Soundbeam 6 Quantity Price: £ 3,640.00 Quantity GamingGaming Hub Quantity Price: £ 3,300.00 Quantity Cost is for full hub package - please select individual items as relevantHub items Select All Sony Playstation 5 Sony Playstation 5 Adaptive Controller Additional Playstation 5 Controller Xbox Series X Xbox Adaptive Controller Additional XBox Controller Logitech Gaming Switch set Games Package Meta Quest 3 & games Quantity Price: £ 570.00 Quantity PODs PlayPOD tent - Large Quantity Price: £ 1,225.00 Quantity Large POD Theme Galactic Space Adventure Magical Princess Palace Polar Ice Igloo Rumble in the Jungle Sub Aqua Quest Sunset Safari Walking with Dinosaurs Please specify which theme you would like. Note that small and large themes are not interchangeable.POD tent - Small Quantity Price: £ 1,225.00 Quantity Small POD Theme Galactic Space Adventure Magical Princess Palace Polar Ice Igloo Rumble in the Jungle Sub Aqua Quest Sunset Safari Walking with Dinosaurs Please specify which theme you would like. Note that small and large themes are not interchangeable.POD extra themes Quantity Price: £ 300.00 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.CamerasWildlife Window (max. cost) Quantity Price: £ 640.00 Quantity Type of Camera WiFi Camera SIM Card Camera Please specify what kind of camera you would prefer for the Wildlife Window.GoPro Camera Bundle Quantity Price: £ 400.00 Quantity Waterproof Camera Quantity Price: £ 215.00 Quantity iPadsiPad (inc. case) Quantity Price: £ 450.00 Quantity iPad charging (Large cabinet) Quantity Price: £ 900.00 Quantity iPad charging (Desktop) Quantity Price: £ 80.00 Quantity Would you you like Grid 3 installed on your iPads? Yes No How many flexi arms would you like with your iPads?Please enter a number greater than or equal to 0.SwitchesSwitch Toy Quantity Price: £ 180.00 Quantity Cost includes toy and switchBasic Switches (max. cost) Quantity Price: £ 265.00 Quantity Cost of each switch varies. Please select switch preferences from types.Switch types Small Button Switch (for toys & iClick) Candy Corn Proximity (for toys & iClick) Vibe Light Select which switches you request.How many Small Button Switches do you need?Please enter a number greater than or equal to 0.Please note that they come in a pack of 4.How many Candy Corn Proximity switches do you need?Please enter a number greater than or equal to 0.iClick Quantity Price: £ 210.00 Quantity Large Wireless Switch (for iClick) Quantity Price: £ 70.00 Quantity BigMac Recordable Switch Quantity Price: £ 210.00 Quantity Cosmo (8 switches) Quantity Price: £ 1,000.00 Quantity AudioOddBalls Quantity Price: £ 100.00 Quantity Bluetooth Waterproof Speaker Quantity Price: £ 45.00 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.