Individual Grant Application "*" indicates required fields Should you need any assistance with this form, or have any questions, please get in touch with us by calling 08 8981 2544 or email [email protected].1. Applicant DetailsChild's Ful Name* First Last Child's Residential Address* Street Address City Australian Capital TerritoryNorthern TerritoryNew South WalesQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Postcode Child’s Date of Birth* MM slash DD slash YYYY Child's age*What gender does the child identify as:*FemaleMaleNon-binaryPrefer not to answerIs the child Aboriginal or Torres Islander origin?YesNoIs this child a NT resident?*YesNoMain language spoken at home*Description of the child’s disadvantage, illness or disability:*This application will be reviewed by the Variety NT Kids Support Committee, please share any additional information about the child or family's situation, to be considered by the Committee.2. Funding RequestDetails of the equipment and how the equipment will be used, benefit to the child and expected outcomesNumber of year’s equipment expected to last:How many children will benefit from this grant?Total Equipment Cost (ex GST) and delivery:*Are you able to make any financial contribution to this application?*YesNoHow much are you able to contribute?*Preferred Supplier Name:Please provide a minimum of 2 quotes, unless there is only one manufacturer.Does the child have an NDIS plan?*YesWaiting for application resultAwaiting planning meetingNot eligible for NDISHas the requested item been applied for with NDIS?*YesNoPlease attach NDIS evidence for declined, partial funding or expected waiting period*Max. file size: 512 MB.Have you previously received assistance from Variety NT?*YesNoPlease detail equipment and year of grant*Application Reference (if known)3. Family DetailsParent/Carer Full Name:* First Last Relationship to child:*Mobile Phone Number:*Email* Current Housing Situation:* Renting Mortgage Own Home Government/assisted housing Or other amount? Does Parent/Carer reside with the child:* Yes No Number of Dependents (under 18 years):*Ages of Dependents*separate with a comma4. Finance DetailsParent/Carer 1 employment status:* Employed (full time, part time or casual) Employed plus receiving Centrelink Self Employed Or other amount? Parent/Carer 1 annual income:*Add Parent/Carer Add Parent/Carer Parent/Carer 2 employment status:* Employed (full time, part time or casual) Employed plus receiving Centrelink Self Employed Or other amount? Parent/Carer 2 annual income:*Finance items required: Each Parent/ Carer to please provide a copy of the following: - Most recent ATO Income Statement - Attached Payslip - Tax Return (most recent) - Please attach Centrelink Activity Statement or letter of Refugee or Asylum Seeker StatusMost recent Payslip*Max. file size: 512 MB.Most recent ATO Income Statement*Max. file size: 512 MB.Most recent Tax Return*Max. file size: 512 MB.Centrelink Activity Statement or letter of Refugee or Asylum Seeker Status*Max. file size: 512 MB.5. Supporting DocumentA child with a disability will require a referee from a health care professional (occupational therapist, physiotherapist etc).In the case of a disadvantaged child (without a disability) will require a referee from a teacher, social worker, case worker or someone who can verify the child's circumstances. The referee letter must be dated within 6 months and must reference: - Verify the child’s condition. - A description of the requested item/s and the need - How the request will support the overall care plan and benefit the child - The anticipated outcomes of receiving the equipment for child and familyReferee Full Name*Title/Position*Organisation/Company*Office Phone NumberMobile Phone Number*Primary Email* Attach Supporting Documentation*Max. file size: 512 MB.6. Privacy Collection StatementConfirmation* I have read and understand the Privacy Collection Statement Thank you for your time to complete this application. Please check your email inbox for updates as the application progresses (check junk/spam if not in your immediate inbox). Application vetting is carried out by our Kids Support Committee. Please allow 1-2 weeks for updates following confirmation of receiving your application. Feel free to check on the form at any stage by calling 08 89812544 or email [email protected] CAPTCHAReminder! If this application has been approved, please remember to set a calendar reminder to check in with the recipient in 3- and 6-months' time and obtain details for grant story release. Δ
