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Application for Assistance
2020-09-15T12:30:35+00:00
Application For Assistance Form
SECTION A: Type of Assistance
Tick
ONE BOX ONLY
below to select the type of assistance your require:
(if you need to apply for more than one type of assistance please fill out a separate application form each)
Type of Assistance
*
Hardship
Old People's Fund
Sports
Education
Carer
Medical
Funeral
SECTION B: Personal Details
First Name:
*
Last Name:
*
D.O.B:
*
DD slash MM slash YYYY
Email:
*
Phone:
*
Address:
*
Street Address
Suburb
*
State / Province / Region
*
Postcode
*
ATTENTION: If your application is relating to Hardship and OPF please proceed to Section G, H & I.
SECTION C: Application for a child
Please provide the following information:
Child's Full Name
Child's Full Name
*
DOB
MM slash DD slash YYYY
DOB
*
MM slash DD slash YYYY
Year/Class
Year/Class
*
Address of the Child
SECTION D: Medical Assistance
Please provide the following information & documents for assistance relating to Medical:
A letter from the medical professional or social support worker
Letter from the medical professional or social support worker
Max. file size: 128 MB.
Date of the appointment:
DD slash MM slash YYYY
SECTION E: Carer's Assistance
Please provide the following information & documents for assistance relating to Carer:
A letter from the medical professional / social support worker
Letter from the medical professional / social support worker
Max. file size: 128 MB.
Carer's Assistance
Appointment Date
MM slash DD slash YYYY
Name of the Patient
Relationship to the Patient
SECTION F: Sports Assistance
Please provide the following documents for assistance relating to Sports:
Completed registration of the sports event, lessons or course
Completed registration form
Max. file size: 128 MB.
Please provide the following documents for assistance relating to Sports:
A support letter from the sports institution
Support letter from the sports institution
Max. file size: 128 MB.
SECTION G: Funeral Expense Assistance
Funeral Notice
Funeral Notice
Max. file size: 128 MB.
Funeral Date
DD slash MM slash YYYY
SECTION H: Expenses Requested
Expenses Requested
What is the money for?
*
Who is being paid?
*
Requested Amount
*
SECTION I: Why do you need help?
(What has happened recently that has caused you to ask for help?)
SECTION J: Declaration
*
I declare that the above information is true.
*
Signature
*
TIP: You can draw your signature in the box below.
Attachment:
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 128 MB.
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