Funding Application

Application for Financial Assistance

All Applications and supporting documentation are confidential and treated with respect

Completion of all questions on this application form is essential and supporting documentation must be attached as requested.

Name of Child:

Address:

Date of Birth:

Medical Diagnosis / Condition:

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Max File Size 15MB

(You must attach supporting documentation from 2 medical sources. At least 1 being a specialist such as a paediatrician and the other either another specialist or GP)

Family Income

(net monthly) $

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Max File Size 15MB

(You must attach supporting documentation for verification, such as payslips)

Name of Parent / Guardian:

Address of Parent / Guardian:

Contact Mobile of Parent / Guardian:

Email address of Parent / Guardian:

Number of siblings that live with child:

Ages of siblings that live with child:

Financial Assistance (net monthly) $

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Max File Size 15MB

(You must attach supporting documentation for verification such as Centrelink statement)

Current bank details to show debts such as credit cards, loans and savings

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Max File Size 15MB

Monthly expenses (approx.): $

(You must attach support current bank statements that show previous 2 months balances)

Please circle - Do you:

Is the child currently being treated as an inpatient in hospital?

Does the child have upcoming surgeries that are expected?

Does the family have any other means of financial support? Family or friends that can assist?

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Max File Size 15MB

(Please attach a list of main expenses with estimated costs eg: Mortgage/ Rent, Food, Fuel, Medical)

Angie Mansey - Charity Director/ Founder

Phone: 0417 963 092 

Donation Details

BSB: 124 001

Account: 22888397

Driven By KM Ltd is registered with Australian Charities and Not-for-profits Commission and has Deductible Gift Recipients status.

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