Better Tomorrows Application

"*" indicates required fields

1. Applicant

Name*

First Last

Date of birth*

2. Medical Details

Diagnosis*

Date of diagnosis*

If you have the following please attach

Letter of diagnosis or other documentation.

Max. file size: 50 MB.

If no, please obtain this and attach to continue your application.

When was treatment completed?

Have there been any side effects from the treatment, (eg: hearing loss, vision loss) please explain:

Have you had recent assessments of these side effects:

Yes

If yes, please attach reports if available.

Max. file size: 50 MB.

3. Personal Information

Home Address

Street Address City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

4. Home Details

What language/s do you speak at home?

5. What is your education/ Vocation Goal and needs

What is your education/ Vocation Goal and needs

6. Please outline the Support being applied for including the cost

Please outline the Support being applied for including the cost

7. Why would this be important to you?

Why would this be important to you?

8. What outcome would you like to achieve if this request is agreed to?

What outcome would you like to achieve if this request is agreed to?

9. Privacy Statement

All personal information collected in this application will be dealt with confidentially at all times.
Your details will not be accessed for any other use.

10. Application Approval

Once approved, payment of support requests will be made directly to the supplier.
No finance will be allocated to the applicant or their family.

11. Consent

I consent that the information above on the application form is correct to the best of my knowledge.
I consent to the participation in the Better Tomorrows Adolescent Program
I consent to be asked about media involvement in recognition of the program

12. Signature of Applicant

Name

First Last

Date

Signature

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DISCLAIMER: This guide has been written for educational purposes only, it cannot be used for diagnosing or treating a health problem or a disease. If you have or suspect that you or your child may have a health problem, you should consult your Doctor. No responsibility can be accepted for information on any linked page, please read the provider’s own disclaimer where appropriate.