Brainwave equipment and therapy funding program 1 2 3 4 5 PLEASE NOTE APPLICATIONS ARE NOW CLOSED FOR 2020. ALL APPLICATIONS WILL NOW BE REIVEIWED IN FEBRUARY 2021. Before you start...Please ensure that you have the following items ready before you begin filling out this form: • Support letter saved as a .PDF, .DOC or .DOCX file • Quote saved as a .PDF, .DOC or .DOCX file Are you eligible?*Yes, child is registered with BrainwaveNoUnsurePlease contact Brainwave on admin@brainwave.org.auPlease Register for Brainwave Child with neurological conditionTick which category applies* Australian citizen Permanent visa Other Please contact Brainwave on admin@brainwave.org.auChild*First nameSurnameDate of birth Child Gender*FemaleMaleAddress* Street Address Suburb State Postcode State*VICNSWACTSAWAQldTasNT Hospital / medical detailsWhat is the child’s diagnosis?* Acquired brain injury Brain tumor Cerebral palsy Encephalitis Epilepsy Hydrocephalus Multiple sclerosis Muscular dystrophy Stroke If child's diagnosis is not listed please contact Brainwave 1300 766 5606Treating Hospital/Health Service*Primary Medical Specialist*Full NameMedical ProfessionTelephone Parent/Guardian detailsPlease select ONE parent/guardian as the main contact and complete the following details:*First nameSurnameEmailMobile Funding request*I am the overseeing Hospital/ Medical representative. I have obtained verbal consent to submit the funding application on behalf of the familyFull Name*Title/position*Telephone*Email* What are you applying for?*EquipmentTherapyProvide details of what you are applying for?*Has funding been sought from other sources? Please detail*Amount requested $*Upload a letter of support from hospital/ medical service representative overseeing the care of the child*Accepted file types: pdf, do.Please note that only PDF, .doc and .docx files can be uploadedQuote for equipment, therapy or financial assistance*Accepted file types: pdf, do.Please note that only PDF, .doc and .docx files can be uploaded* I consent to Brainwave contacting the Hospital/Medical representative to verify any information obtained on this form * I am happy to contribute a testimonial/personal story about my Brainwave Equipment and Therapy funding experience I am happy to contribute a photo to support my Brainwave Equipment Therapy funding experience For further information email admin@brainwave.org.au Ph: 1300 766 819NameThis field is for validation purposes and should be left unchanged.
