Application Forprimary Assistance

Application forPrimary Assistance

All applications are to be completed by a social worker or other appropriate health professional.

Please refer to the Financial Assistance Program Guidelines or the Application Process documents, for details on eligibility criteria and other relevant information.

It is preferred that all applications are typed (where possible) for greater legibility.

Once completed, please email the application form and any relevant documentation and bills to . Only applications that have been fully completed with all necessary documentation attached and received by Redkite by 8pm Friday will be considered for approval the following week.

Please note:forms to apply for Higher Needs Assistance or Exceptional Needs Assistance are separate documents– if you would like a copy of these forms please download the form from the financial assistance page on our website:

Is this the family’s first application with Redkite?

YesIf YES, Please complete all sections of the form

NoIf NO, Please only completehighlighted sections 1a, 1b, 2a, 3, 4 & 5 –

unless any details have changed since last application.

SECTION 4: PRIVACY NOTICE AND APPLICANT/S DECLARATION OF CONSENT

Redkite respects your right to privacy. In order to determine your eligibility for assistance and provide this service to you, we need your consent to collect, store and use your personal information, including sensitive information such as health details. Here are a few things we’d like you to know about the way Redkite handles your private data.

PRIVACY STATEMENT

The personal information you provide here is collected, stored and used by Redkite in accordance with the Australian Privacy Principles and our Privacy Statement to determine eligibility, provide services and send Redkite communications to you and other members of your family. We may also seek your participation in relevant research and evaluation involving your personal information. For further information on the way Redkite manages and uses your personal information please refer to the Redkite Privacy Statement on our website:

By submitting this form, I consent to having the personal information I have provided in this form collected, stored and used by Redkite in accordance with the above.

DECLARATION OF CONSENT

Primary Applicant (This isthe main contact person for this application. If the diagnosed young person is 18+ and applying for themselves, then they are the Primary Applicant. If a parent or carer is applying on behalf of a diagnosed child or young person (aged 0-24 years), then they are the Primary Applicant

Name of Primary Applicant:Click here to enter text Date):

Signature of Primary Applicant:Click here to enter text

ORReferrer’s signature on behalf of Primary Applicant:Click here to enter text

Diagnosed young person 18+(Complete only if aged 18+ and has not already signed as the Primary Applicant as above)

Name of diagnosed young person:Click here to enter text Date:

Signature of diagnosed young person:Click here to enter text

ORReferrer’s signature on behalf of diagnosed young person:Click here to enter text

Referrer of this application

If signed by the Referrer, your signature declares that verbal consent has been obtained from the Primary Applicant and/or diagnosed young person 18+ and the individual/s have consented to their contact details and other personal information being collected, stored and used by Redkite for the purposes specified in this document, and this has been recorded in your case notes. If this application has been faxed to Redkite by a Referrer you are required to enter the details of the Primary Applicant and/or diagnosed young person 18+ above and to physically sign this form. If this application has been emailed to Redkite by a Referrer, you are not required to physically sign this form. HOWEVER you are required to enter the details of the Primary Applicant and/or diagnosed young person 18+ above, enter your details below and have a valid email signature with your full name, title and hospital details to facilitate your consent on behalf of the Primary Applicant and/or diagnosed young person 18+.

Signature of Referrer: Click here to enter text Date:

If signatures are not provided by the Primary Applicant and/or diagnosed young person 18+ OR by the Referrer on their behalf, Redkite cannot process the application.

SECTION 5: ASSISTANCE PAYMENT DETAILS

Please complete only the details relevant to this application – if applying for both bills and vouchers please complete both the bills and vouchers categories below.

BILLS - maximum 3 bills per application

NOTE: Redkite only pays the biller directly; we do not pay families or reimburse families for bills already paid. Redkite also only pays for bills via BPAY, direct transfer and cheque. Please be advised that cheque payments do delay the process of finalising payment of bills in full and as such Redkite would prefer that all bills include BPAY or direct transfer details.

Please submit full copies of the most current unpaid bill/s – all bills must include a contact person and address, total cost and relevant payment details. Please note that if the bill/s provided are in the name of another immediate family member, we require their details to process the application.

Please complete the payment details below for each bill if payment details on bills attached are not clear. In order to complete payments, Redkite will need method of payment and payment details on all bills marked clearly.

Number of bills:Click here to enter textTotal amount of all bills $

VOUCHERS–recommended $200 combined total per application.

Food: Petrol:

Select a valueFood $50Food $100Food $150Food $200 Select a valueFuel $50Fuel $100Fuel $150Fuel $200

Voucher to be sent to:

Select from down To social worker (Redkite preferred)To family directly

If to family and they’re at different to the address listed above, please send to:

Street: Click here to enter text

Suburb: Click here to enter text State:Select a StateNSWVICQLDTASNTSAWA Postcode:Click here to enter text

1

Version 4 Last updated 22 June 2017