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:
Name of Parent / Guardian:
Address of Parent / Guardian:
Date of Birth:
Contact Mobile of Parent / Guardian:
Medical Diagnosis / Condition:
Email address of Parent / Guardian:
(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)
Number of siblings that live with child:
Ages of siblings that live with child:
Family Income (net monthly) $
Financial Assistance (net monthly) $
(You must attach supporting documentation for verification, such as payslips)
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?
(You must attach supporting documentation for verification such as Centrelink statement)
(Please attach a list of main expenses with estimated costs eg: Mortgage/ Rent, Food, Fuel, Medical)
What is the most pressing family issue at present?
Submission of the application to Driven By KM does not expressly mean or imply that Driven By KM has accepted your application. Driven By KM is under no obligation legal or otherwise to process your application to a successful conclusion. Each application will be determined on its merits, and within Driven By KM’s funding guidelines. Driven By KM is not liable for any loss or damages whatsoever upon your application being declined.
Your privacy is respected by Driven By KM. The personal information you provide on this form (including sensitive information about health matters) will be used to assess your eligibility. It may be provided to organisations that assist us, or as required or authorised by law, but we will not use any of your sensitive information for marketing purposes, without your prior consent. If you have any privacy concerns or would like to verify information held about you please contact our team on the following details: firstname.lastname@example.org or phone: 0417 963 092
I consent to Driven By KM collecting the information provided on this form. I understand that if I do not provide the information requested, I may be ineligible to receive assistance from Driven By KM.
Please contact our Team who will endeavour to visit you as soon as possible to have a compulsory interview and collect all your completed forms on the following: email@example.com or phone: 0417 963 092
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