Special Circumstances Grant November 18th 2021 Special Circumstances Grant Application Step 1 of 4 25% Are you or a family member affected by Epidermolysis Bullosa (EB)?* Yes No Do you reside in the Republic of Ireland?* Yes No Please note: we can only accept applications from people who are living with EB and who currently reside in the Republic of Ireland. Name of Applicant* First Last Please complete the Name, Date of Birth and Gender of all those living with EB in your household:*First NameSurnameDate of BirthGenderRelationship to Applicant Click on the plus + icon to add a new lineType of EB*Please Select From Drop DownEB Simplex (EBS)Dominant Dystrophic EB (DDEB)Recessive Dystrophic EB (RDEB)Junctional EB (JEB)Kindler EB (KEB)UnknownOtherPlease provide further details below:* EBS Subtype* Localised Intermediate Severe (Dowling-Meara) Unknown DDEB Subtype* Localised Intermediate Unknown RDEB Subtype* Intermediate Severe Unknown JEB Subtype* Intermediate Severe Unknown Address* Street Address Address Line 2 City/Town County Eircode Email* Mobile No*Landline No What is the purpose of the grant request?*How will the grant improve quality of life?*Have you sought funding from any other body?* Yes No Please provide details*What is the total cost?* What contribution are you seeking from DEBRA Ireland?* Please upload receipt(s) Drop files here or Select files Max. file size: 64 MB. Do you have a recommendation letter from a Health Care Professional/Occupational Therapist?* Yes No Please upload recommendation letter and any other supporting documentation to assist with your application: Drop files here or Select files Max. file size: 64 MB.
