"*" 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)TikTokPrimary contact (person completing this form)* First Last Email address* Phone number*Lifelites Champion?* Yes No Secondary contact* First Last Email address* Phone number*Lifelites Champion?* Yes No Communications Lead* First Last Tell who we should speak to about celebrating this support should you be successful.Email address* Phone number*Chief Executive / Director of Care* First Last Email address* Phone number* Section 2 – About your organisationDescribe your organisation’s mission and objectives.*Tell us about what your organisation does, where you operate and what impact you are achieving (Max 1,000 characters)How many children & young people with life-limiting conditions do you support on average per year?*How many people benefit from your work indirectly per year?*Include parents, siblings and those you support with bereavement servicesTell us about the children & young people you support.*How old are they, what clinical and care needs do they have, what are their challenges (Max 1,000 characters)If you provide a community and/or Hospice at Home service... Please state the number of children you support and how this service is deliveredHow many children and young people fit into the following age brackets?Please state zero (0) if none0-5*6-10*11-18*18+*How many staff members are currently in the following teams?Please state zero (0) if noneCare*Play / Activities / Therapy*Community* Section 3 – About your current Lifelites package*Please note: This section is only applicable to services who have received Lifelites package in the past*What part of the Lifelites package gets the most use and what impact does this have?*Lifelites wants you to identify what works well and what doesn’t work so well in your existing package. This helps us to recognise if there are any changes we need to make and if you have any training needs. The more information you provide us the better as we can adjust our offer to suit your needs. Section 4 – Application for Lifelites supportIMPORTANT - 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.EyegazeQuantity requestedDo you require a new stand for your Eyegaze? Rehadapt stand (floor stand) Portable clamp stand No We can provide Rehadapt stands or portable stands, please consider if your existing stand will work.Tilt TableQuantity requestedSoundbeam 6Quantity requestedWildlife WindowSpecify how many camera units you requireMagic CarpetMobile Magic Carpet (New)Quantity requestedMobile Magic Carpet (Refurbishment)Quantity requested. *Please note: Only Magic Carpets donated in your last package are eligible for refurbishment.GamingInteractive Entertainment HubQuantity requested. Hub items Select All Sony Playstation 5 XBox X Microsoft Adaptive Controller Additional XBox controller Logitech Gaming Switch set Sony PS5 Adaptive Controller Games package Each Hub we provide is unique. Please select what you would like to include in your Hub. Consult the brochure for information on what is on offer.Meta Quest 3 Virtual Reality & GamesQuantity requested. PODs PlayPODs tent (Large)Quantity requestedPODs tent (Small)Quantity requestedPODs (extra themes)Quantity requestedExtra 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 theme(s) you would likePortable 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.CamerasGoProQuantity requestedWaterproof CameraQuantity requestediPadsiPads (inc. case & extras)Quantity requestediPad charging (Large cabinet)Quantity requestediPad charging (Desktop)Quantity requestedWill you require flexi arms? Yes No SwitchesCOSMO (6 switches)Quantity requestediClickQuantity requestedBasic SwitchesQuantity requestedSwitch types Big Mac Recordable Switch Small Button Switch (for toys & iClick) Large Wireless Switch (for iClick) Candy Corn Proximity Switch (for toys & iClick) Select which switches you requestSwitch ToysQuantity requestedStorage & TransportationWe provide Lifelites Tech Trunks to enable teams to store and transport equipment. Please note these are suitcases and not pre-filled with technologyTech Trunk (Large)Quantity requestedTech Trunk (Medium)Quantity requestedTech Trunk (Small)Quantity requestedPlease tell us about any other assistive or sensory technology that you have identified and would like us to consider, including quantity and price Section 5 - ImpactLifelites will use the information you provide in this section to understand the needs of your service and build a technology package suited to the children and families in your care. The most important thing to tell us in this section is why you need the equipment and what impact you think it will have on the children you support.How will this technology be used?*Please provide an explanation of how the technology that you have requested will be used. Please refer to the specific pieces of technology in your response. (Max 2,000 characters)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 6 - Additional InformationPlease provide any further information you feel is relevant to this applicationPlease upload a copy of your children’s safeguarding policy (and adults if applicable)*Max. file size: 32 MB.Please upload a copy of your most recent accounts*Max. file size: 32 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.NameThis field is for validation purposes and should be left unchanged.