Apply

1. Please read the Guidelines for Funding. This clarifies who we fund and what we fund and will save you time in applying.

2. Check rare disease prevalence on Orpha.net and enter this in the online application form.

3. Ensure the product or service is something we fund.

4. Obtain at least one current, written quote for the product or service, from an Australian Supplier in Australian Dollars.

5. Inform your Medical Specialist (not a General Practitioner or Therapist) that you are applying for a Grant as you will need their written support that the disease is rare and the product or service will assist you in managing.

6. Gather birth certificate, citizenship/residency (passport, colour copy of Medicare Card, birth certificate), product/service quote, tax return, NDIS information (including approval/decline reason) and pay evidence for all income earners in your household. All supporting documentation must be submitted prior to the close of the Grant Round.

7. Allow yourself enough time to complete the form in one sitting as it does not save.

Please contact us if you have any difficulties.

Telephone: 1300 66 99 35
Email: grants@stevewaughfoundation.com.au

Privacy Clause

The Steve Waugh Foundation agrees to maintain all of the information provided in this application form and any supplementary materials private and confidential and not to disclose this information to any third party outside of the Steve Waugh Foundation without permission in writing from the applicant in accordance with the Privacy Act.

The Steve Waugh Foundation may sometimes publish reports on its work. These reports will include de-identified information only - names and other personal details will only be used with the permission of the applicant, their parents or guardian.

SECTION A. Your Contact Information
Please provide your details as the contact person for this Grant Application

First Name

Please provide your First Name

Middle Name/s

Please provide your Middle Name/s

Last Name

Please provide your Last Name

Email Address

Please ensure you are providing a correct email address for correspondence

Mobile Phone Number

Home/Landline Number

Please provide a landline home telephone number if you have one

Address

For example "Unit 2/42 Wallaby Way"

Suburb

Post Code

State

SECTION B. Recipient Information
Please provide the details of the Grant Recipient

Recipient First Name

Please provide the First Name of the Grant Recipient

Recipient Middle Name

Recipient Last Name

Please provide the Last Name of the Grant Recipient

Recipient Gender

Date Of Birth

Please provide the date of birth of the Grant Recipient

Recipient Age (at date of application)

Diagnosis

Please state the name of the Rare Disease affecting the intended Grant Recipient

Go to Orphanet to research the prevalance and Orpha Number of the Rare Disease.

http://www.orpha.net/consor/cgi-bin/Disease.php?lng=EN

If you can't find an Oprhanet Code, please write "not known".

ORPHA Number

Prevalance

Please choose from the dropdown options.

SECTION C. Health Insurance Details

Medicare Number

Recipient's Medicare Number

Private Health Insurance Provider

Private Health Insurance Provider Number

Private Health Insurance Level of Cover

SECTION D. Funding Request
Please provide a description of the product or service you are requesting and a short description of the benefits.

Description of product or service requested

For example "Physiotherapy Sessions"

Benefit to recipient

Please describe how the product or service will benefit the recipient

Total Funding Requested

Please state the total funding being requested in this grant in whole numbers only. You do not need to add the "$" symbol

Breakdown of funding requested

Eg: "26 weeks physiotherapy sessions @ $110 per session = $2860"

SECTION E. Recipient Siblings

Number of Siblings

Sibling 1 Name

Sibling 1 Date of Birth

Sibling 2 Name

Sibling 2 Date or Birth

Sibling 3 Name

Sibling 3 Date of Birth

SECTION F. Household Income and Expenses
Please provide information on the income and expenses in the household of the recipient

Household Income

Single or Two parent / guardian home

Please choose from the dropdown options.

Name of 1st person receiving household income

1st person monthly income

If you receive payments at a different frequency please calculate your monthly average rate

Name of 2nd person receiving household income

2nd person monthly income

If you receive payments at a different frequency please calculate your monthly average rate

Household Expenses
Please indicate your average monthly household expenses in whole numbers only. Eg: 1000 (with no $ sign, no decimal)

Housing Costs (Rent/Mortgage)

Average Monthly Housing costs (accepts whole numbers only)

Utilities (water/land/gas/electricity/council rates)

Average Monthly Rates costs (accepts whole numbers only)

Food

Average Monthly Food costs (accepts whole numbers only)

Medical expenses

Average Monthly Medical Expenses (accepts whole numbers only)

Education & Recreation

Average Monthly Recreation & Education expenses (accepts whole numbers only)

Child Care

Average Monthly Child Care expenses (accepts whole numbers only)

Insurance fees

Average Monthly Insurance Fees (accepts whole numbers only)

Total monthly expenses

Total of Monthly Household Expenses (accepts whole numbers only)

SECTION G. Medical Specialist Details
Please provide the contact details of your Medical Specialist.

Medical Specialist Title

(Dr / Prof / etc)

Medical Specialist First Name

Medical Specialist Last Name

Medical Specialist Email

Medical Speciality

Eg: Paediatrician

Medical Specialist Phone number

SECTION H. Certification

Alternative funding sought

I confirm I have made all efforts to secure alternative funding if it is available. I have applied to the National Disability Insurance Scheme (NDIS). I have used all funding avaliable through Medicare's Cronic Health Care Plan and Mental Health Care Plan via my General Practitioner (GP). I have used all services available through my private health insurance (if applicable)

Grant criteria understood

I have read and understood the Steve Waugh Foundation's guidelines for Individual Grants and that my application is subject to the Grant Funding criteria

True and Correct Declaration

I declare under penalty of the laws of Australia that the answers I have given in this application and the documents I will provide are correct and true to the best of my knowledge and belief. I declare that I have read and understood the application instructions, declarations and all information related to this application

Information use acknowledged

I acknowledge that if my application is successful I will be required to complete a Successful Applicant Agreement, Public Relations and Media Consent Form and supply a current photograph of the applicant