Brainwave equipment and therapy funding program 1 2 3 4 5 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.
