Brainwave equipment and therapy funding program 1 2 3 4 5 Before you start...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 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 and can be contacted to verify information on this form. 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?*Is the child registered with the NDIS?*Not appliedNot eligibleIn application processYesYes, under plan reviewYes, awaiting appealHas 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 am happy to contribute and support a testimonial/personal story regarding this Brainwave Equipment and Therapy funding experience I / child's primary contact authorise use of deidentified (unless agreed otherwise) details and photo included in this application for fundraising, publicity or other purposes to help highlight Brainwave's impact. This might include (but is not limited to), the right to use them in their printed and online publicity, social media, press releases and other mediums. For further information email admin@brainwave.org.au Ph: 1300 766 819EmailThis field is for validation purposes and should be left unchanged.
