Application Form - Cotton Industry War Memorial Trust

Convalescent Scheme

Application Process

Step 1 of 4

In accordance with the rules of the Trust, I wish to make application to the Trustees to be allowed a period of Convalescence as recommended by my doctor and supported by my sponsor.
I authorise the Trust to use the information provided on this application form to make a hotel booking for convalescence and maintaining a record on the Trust Register of bookings.
I understand that this information will be securely stored and available to me for a period of two years, following which it will be securely destroyed. Limited details of all bookings will be maintained on the Trust Convalescence Register.

I am fully aware that any false information on this Application Form could constitute a criminal offence and lead to legal action. I hereby certify all information is correct.

Todays Date

Signed

PLEASE READ THE WHOLE OF THIS FORM CAREFULLY. EACH QUESTION MUST BE ANSWERED IN FULL. FAILURE TO COMPLETE AS INDICATED WILL RENDER THE APPLICATION INVALID.

Your Name

Mr, Mrs, Ms Surname Forename (s)

Date of Birth

Age (Years)

Address

Street Address City ZIP / Postal Code

Your Email Address

Phone

Please indicate if you wish one or two weeks convalescence

One Week

Two Weeks

Relation or friend who may be contacted in case of illness

Name

Full Name

Address

Street Name and House Number

Postcode

ZIP / Postal Code

Phone Number

Telephone Number

All first time applicants must provide evidence of employment in the Recognised Textile Industry. NB See page 4 Rule 2 (a)

How long have you been, or were you, employed in the Recognised Textile Industry

Are you still employed in the Textile Industry

Yes

Your Previous Employers-
Please give name and address of current/last Textile employer:

Name

Full Name

Address

Street Name and House Number

Postcode

ZIP / Postal Code

Phone Number

Telephone Number

If you have retired from or left the Recognised Textile Industry you must state:-

Date of retirement / leaving

Have you previously been allowed Convalescence under the Trust Scheme

Yes

If YES please state previous DATES

Months

Years

PLEASE READ PAGES 2 AND 3 AND ALSO THE RULES OF THE SCHEME ON PAGE 4

TO BE COMPLETED BY SPONSORS

It should be clearly noted that only AUTHORISED SPONSORS will be recognised by this Trust in connections with the completion of page two of this application form on behalf of those applicants applying for Convalescence. Sponsors from the Trade Unions, Employers, Employer Associations or other organisations recognised by the Trust must keep the Secretary informed of any changes in respect of those officers or staff authorised to sign page two of the application form.

Name of Applicant

First Last

Applicants Category (as defined below)

CATEGORY A
Shall consist of those currently employed in the industry.

CATEGORY B
Applicants shall consist of those who are no longer employed in the industry but have been so employed within the last FORTY YEARS of making application for Convalescence under the Scheme. Applicants shall be under normal retirement age and will be entitled to a MAXIMUM of TEN WEEKS Convalescence (a maximum of two weeks in any one spell), unless and until they return to employment in the industry,

CATEGORY C
Applicants shall consist of those applicants who have been employed in the industry for some time during the past FORTY YEARS prior to making an application for Convalescence under the Scheme and are OVER NORMAL RETIREMENT AGE. They will normally be entitled to a MAXIMUM of Twelve WEEKS Convalescence (a maximum of two weeks in any one spell).

I HEREBY CERTIFY that the above applicant is a beneficiary as defined in The Cotton Industry War Memorial Trust Act 1947, and the Amendment Order 1971, and that this application complies with all the rules of Convalescence Scheme,

Name of Sponsor (i.e. Trade Union, Employer, Authorised signatory):-
Please give name and address of current/last Textile employer:

Name

Full Name

Address

Street Name and House Number

Postcode

ZIP / Postal Code

Phone Number

Telephone Number

Capacity of Authorised Signatory

Todays Date

Signed

PLEASE NOTE
On receiving your application form for Convalescence, unless accompanied by a letter stating dates for your Doctor or Hospital appointments, I shall reserve your accommodation on the earliest date available to the Trust. Refusal of the dates arranged could lead to the cancellation of convalescence, and no further application will be considered for the rest of the year.

Phil Roberts Trust Secretary

CERTIFICATE

(TO BE COMPLETED BY THE APPLICANT'S DOCTOR)

I certify that (Name)

First Last

of (Address of applicant)

Street Address ZIP / Postal Code

Is suffering from (Nature of Accident/Illness)

And would benefit from a period of convalescence arranged by the Trust.
(The terms 'Debility' and 'General Debility' are insufficient; the cause must be fully stated).

Please state:

1. The extent to which any symptoms are controlled by medication

2. In chronic conditions, the severity of the ailment e.g. slight, moderate or severe etc.

Date of accident/onset illness

Is the patient diabetic?

Signed

Address

Street Address

Phone Number

Telephone Number

NOTES TO APPLICANT'S DOCTOR:-

ANY CONVALESCENCE GRANTED WILL BE TAKEN AT A NORMAL COMMERCIAL HOTEL AND NOT AT A SPECIALIST CARE/CONVALESCENT HOME.

The following applications are, therefore, NOT acceptable, and the Doctor must NOT agree to complete the above certificate in respect of the individuals concerned:-

1. Those requiring nursing attention or who cannot get about unaided or who cannot completely attend to all their own requirements or are not considered suitable by reasons of age.

2. Those whose symptoms may be offensive or distressing to the other residents of the Hotels where applicants are staying: e.g. incontinence, fits, fainting or blackouts, mental disorders, extensive skin diseases, etc.

3. Those suffering from pulmonary tuberculosis or any infectious ailments.

THE COTTON INDUSTRY WAR MEMORIAL TRUST

1. APPLICANTS
There shall be three categories of applicant:-
Category 'A' (those currently employed in the cotton textile industry).
Category 'B' (those no longer employed in the cotton textile industry and under normal retirement age)
Category 'C' (those over normal retirement age).

Category 'A' applicants shall have priority over all other application should accommodation be limited

2. CONDITIONS OF ADMISSION, LIMITATIONS ON ADMISSIONS etc.
(a) All first time applicants must provide evidence of employment i.e. pay slip, pension statement or employer correspondence. If you do not have this available, confirmation of your employment history is available by contacting PT Operations Area 2, HM Revenue & Customs, BX9 1AN. Telephone 0300 200 3500.

(b) Category 'A' and Category 'B' applicants still employed must have had an absence from work of at least two weeks by reason of their own illness or injury, which has been certified by their own Doctor, before being able to make application for convalescence under the Trust scheme.

(c) Category 'B' and Category 'C' applicants not in employment must be certified by their own Doctor as having been suffering from their own illness or injury for at least two weeks before being able to make application for convalescence under the Trust scheme.

(d) Sponsors should ensure, to the best of their knowledge, that all applicants are suitable, medically, and socially before submitting their application form to the Honorary Secretary for consideration for period of convalescence.

(e) Page 1 of this application form must be completed in full in BLOCK CAPITALS by the applicant. If the applicant finds any difficulty regarding the completion of page one he/she may wish to seek the assistance of the sponsor either the Trade Union, Employer, Employers Association or whichever organisation provided the application form in the first instance. Failing this, the Secretary will assist if contacted.

(f) APPLICANTS MUST RETURN THEIR APPLICATION FORMS TO THEIR SPONSORS ONCE PAGES 1 AND 3 HAVE BEEN COMPLETED. THE SPONSOR WILL THEN FORWARD THE FORM ON TO THE SECRETARY FOR PROCESSING.

(g) Applicants may apply for a period of convalescence for a duration of either one or two weeks. This choice must be clearly indicated when completing page 1 of this application form. Applicants will only be allowed one period of convalescence per year.

(h) The trust will only be responsible for the costs of normal full board and accommodation at your Hotel as indicated in your letter of confirmation of booking arrangements from the Secretary. Any extras must be paid for by the applicant.

(i) Each person accepted for a period of convalescence will, one week prior to their attendance, receive a personal grant the actual amount of which will be determined by the Trustees from time to time. This grant is to cover the costs of Doctors fees, travel between your home and the hotel, and for incidental travel around about the Hotel and resort.

(j) Applicants may be accompanied at their own costs, with preferential rates available.

In extenuating circumstances, the Secretary of the Trust is authorised to use his discretion and, if necessary, and within reason, depart from the Rules of the Convalescence Scheme.

THE RIGHT IS RESERVED TO DECLINE APPLICATIONS WITHOUT STATING A REASON.