Special Somerset Award Application for Children with SEND

Before you begin: Please read all instructions carefully. If the beneficiary currently attends or has attended a Haringey school, the form must be signed by the Headteacher. Otherwise, documentary evidence of date of birth and Haringey residence is required.

1. Applicant Information

Title *

Mr Mrs Miss Ms Dr Other

Please specify title

Surname *

Forename *

Postcode *

Address *

Home Telephone

Mobile Telephone *

Email Address *

2. Intended Beneficiary Information

Surname *

Forenames *

Date of Birth *

Postcode (if different from applicant)

Home Address (if different from applicant)

Has the beneficiary previously received a Somerset Award? *

Yes No

Previous Award Details (dates, purpose, amounts)

3. School Information

Current or Most Recent School Name *

School Address *

Dates of Attendance - From

4. Purpose of Award

Please select the type of equipment/support requested: *

Information Technology (IT equipment) - Desktop PC, Laptop, iPad

Communication Aid/Software - e.g. iPad with Proloquo/Grid Player, Step by Step communicator

Other (please specify below)

Note: Applications for Communication Aids will be referred to the Haringey Augmentative Communication Service, Speech & Language Therapy, Vale School for assessment. Contact: 020 8801 1313

Equipment Requested (please provide specific details) *

5. Additional Required Information

Professionals Involved (e.g., Teacher, IT Consultant, Healthcare Professional)

Assessment for IT Equipment (if applicable)

Trial Period with Equipment

Programmes/Apps Used

6. Supporting Documents Checklist

Please ensure you include all relevant supporting documents with your application.

Covering letter from applicant (optional)

Letter from school

Letter from healthcare professional

Assessment report / supporting information

Copy of relevant extract from EHCP

Estimate or quote of required equipment costs

Proof of date of birth and Haringey residence (if not attending Haringey school)

7. Declaration

By submitting this form, I confirm that the information provided is accurate and complete. I understand that this application will be assessed according to the Foundation's rules and criteria.

Applicant's Signature *

Date *

For Headteacher (if applicable):
Signature: _________________ Date: _________
Date of Birth and School Attendance Confirmed: _______ (initials)

Submission

Submission is by email to the Clerk of the Foundation:
clerk@tgsf.info

Postal address (if required):
Tottenham Grammar School Foundation
PO Box 81763
London N4 4QD
Telephone: 020 8882 2999