Apply for Assistance

Family Details:

Today's Date *

Surname *

Mother's Name *

Father's Name *

Child's Name *

Child's Date of Birth *

Full Address (Including Post Code) *

Home Phone

Work Phone

Mobile Phone

Fax

Email *

Vehicle Registration Number *

Medical Information:

All information supplied is treated as confidential and will not be disclosed without your written permission.

Doctor's Name *

Doctor's Phone *

Specialist's Name

Specialist's Phone

Hospital Name

Hospital Phone

I/We have private medical insurance cover

I/We hereby give permission for Convoy For Kids Goulburn Inc. to:

Contact our doctorContact our specialistUse our child’s name in media and promotional informationUse our child’s photograph in media and promotional information

Attach supporting documentation e.g. supporting letter from GP/specialist

Provide brief details of your circumstances. The type of assistance sought, and the current level of expense incurred.

Are you currently receiving any benefits under the NDIS scheme? *

YesNo

If you answered 'Yes' to the question above, please provide details below.