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:
Date of Birth:
Medical Diagnosis / Condition:
(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)
(net monthly) $
(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) $
(You must attach supporting documentation for verification such as Centrelink statement)
Current bank details to show debts such as credit cards, loans and savings
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?
(Please attach a list of main expenses with estimated costs eg: Mortgage/ Rent, Food, Fuel, Medical)