Apply for Funding

This application is to be completed by a treating health practitioner for items or services relating directly to the child’s brain illness or injury, and/or impact on the family resulting in emotional, social, or financial hardship. Products and services will be considered where alternative funding sources are not available and are deemed beyond family’s capacity to meet. Please ensure that you have the following items ready before you begin filling out this form:

*Support letter saved as PDF, doc. or docx file
*Quote saved as a PDF, doc. or doxc. file

Is the child already registered with Brainwave?

Please register child with Brainwave before completing this form.

Please contact the admin@brainwave.org.au to check if you are already registered with Brainwave.

Child with neurological condition

Child's First Name

Child's Last Name

Child Date of Birth

Citizenship Status

Child's Neurological Conditions

To select more than one neurological condition please use your command or control key on your keyboard.

Please detail this child's neurological conditions

Parent/Guardian details

Primary Contact First Name

Primary Contact Last Name

Primary Contact Email

Primary Contact Mobile

Please leave no spaces between the numbers

Applicant Declaration

I am the overseeing Hospital/Medical representative and can be contacted to verify information on this form. I have obtained verbal consent to submit the funding application on behalf of the family.

Your First Name

Your Last Name

Your Title

Your Email

Your Phone

please include area code

Funding request

What are you applying for?*

EquipmentTherapy

Please provide details of what you are applying for?

Is the child registered with the NDIS?

Has funding been sought from other sources? Please detail

Amount requested $

Supporting Documentation

Please note that only PDF, .doc and .docx files can be uploaded

Letter of Support

Upload a letter of support from hospital/ medical service representative overseeing the care of the child.

Quote

The quote may be for equipment, therapy or financial assistance.

I am happy to contribute and support a testimonial/personal story regarding this Brainwave Equipment and Therapy funding experience

Please be patient while this form processes - it may take up to 30 seconds.

Contact Information

Apply for Funding

Child with neurological condition

Parent/Guardian details

Applicant Declaration

Funding request

Supporting Documentation

Brainwave Australia Ltd
Call: 1300 766 819
Email: admin@brainwave.org.au

ABN 62 664 658 164

Apply for Funding

Child with neurological condition

Parent/Guardian details

Applicant Declaration

Funding request

Supporting Documentation

Brainwave Australia LtdCall: 1300 766 819Email: admin@brainwave.org.au

ABN 62 664 658 164

Brainwave Australia Ltd
Call: 1300 766 819
Email: admin@brainwave.org.au