Apply for Assistance - Convoy for Kids Goulburn

Today's Date *

Surname *

Mother's Name *

Father's Name *

Child's Name *

Child's Date Of Birth *

Street Address *

City

State/Province

ZIP / Postal Code

Home Phone

Work Phone

Mobile Phone *

Vehicle Registration Number

Email Address *

Medical Information

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

Doctors Name *

Doctors Phone *

Specialist's Name *

Specialist's Phone *

Hospital Name *

Hospital Phone *

I/We have private medical insurance cover *YesNo

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

Please 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

Please provide details of your NDIS scheme.

Please provide your NDIS Plan and Supporting Documentation. *