Register with Brainwave

Brainwave provide support to children under the age of 18 years with a diagnosed neurological condition living in Australia. To register, and have access to our free family events, groups and resources, including our Equipment and Therapies Funding program, please fill in the form below. All information provided is confidential.

Primary Contact Details

Relationship to child

First Name

Last Name

Mobile

Street

Suburb

State

Postcode

Does the child have a Secondary Contact?

Secondary Contact First Name

Secondary Contact Surname

Secondary Contact Email

Secondary Contact Mobile

Child's Details

Child First Name

Child Surname

Child Date of Birth

Child's Gender

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

Please list any other diagnosis that may impact the child's care

Does the child use a Mobility Aid?

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

Please describe the mobility aid the child uses

Treating Hospital/Health Service

Other Hospital/Health Service

NDIS Details

Does your child have a NDIS plan?

Which of the below applies to you

Would you like information and support to navigate the NDIS and your plan?

Applicant Declaration

How did you hear about Brainwave?

If Other, please specify

Who is making this declaration?

I declare that the information on the registration form is correct.

I am a medical, hospital or healthcare representative, and I confirm that I have explained Brainwave services and registration to my client (my details are added below).

Applicant First Name

Applicant Last Name

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

By completing this form, you will automatically receive communications about how Brainwave can support you, upcoming events and the latest information and resources.

Contact Information

Register with Brainwave

Primary Contact Details

Child's Details

NDIS Details

Applicant Declaration

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

ABN 62 664 658 164

Register with Brainwave

Primary Contact Details

Child's Details

NDIS Details

Applicant Declaration

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