Application Forfinancial Assistance

Application forFinancial 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 contact Redkite at

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 1a: REFERRER DETAILS
Name: Click here to enter text.
Hospital: Click here to enter text.
State: Choose an item.
Phone no: Click here to enter text.
Email: Click here to enter text.
SECTION 1b: DIAGNOSED CHILD/YP DETAILS
Name of diagnosed child / young person (0-24 years): Click here to enter text.
Gender: ☐ Male ☐ Female ☐ Indeterminate/ Intersex/ Unspecified
Date of Birth:
Treatment Stage: ☐ On Treatment ☐ Relapse ☐ Off Treatment ☐ Palliative ☐ Deceased
If applicable:
Relapse date:
Off treatment date:
Date of death:
SECTION 1c: DIAGNOSIS INFORMATION
(to be completed if new to Redkite, or if details have changed since last application)
Initial Diagnosis: Initial Diagnosis Date:
If applicable
Secondary Diagnosis: Secondary Diagnosis Date:
SECTION 2a: PRIMARY APPLICANT DETAILS
Primary Applicant Details
‘Primary Applicant’ refers to the 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/young person (aged 0-24 years), then they are the Primary Applicant.
Who is the Primary Applicant? ☐ Diagnosed young person 18+ ☐Mother ☐Father ☐ Guardian ☐Partner
☐ Other (please specify)
Name of primary applicant: Click here to enter text.
SECTION 2b: DEMOGRAPHIC DETAILS
(to be completed if new to Redkite, or if details have changed since last application)
Gender: ☐ Male ☐ Female ☐ Indeterminate/ Intersex/ Unspecified
Please ensure you provide all contact details (email, phone; mobile or home, and full address).
Email: Click here to enter text.
Mobile: Click here to enter text. Home phone: Click here to enter text.
Street address: Click here to enter text.
Suburb: Click here to enter text. State: Choose an item. Postcode: Click here to enter text.
Do you identify as being of Aboriginal and/or Torres Strait Islander origin?
NB:Redkite is capturing this demographic data to inform future program development and service provision in becoming a culturally responsive organisation – your answer will not affect the outcome of this application.
☐ NO ☐ YES – Aboriginal ☐ YES – Torres Strait Islander ☐ YES – Both Aboriginal and Torres Strait Islander
Is English your first language? ☐ YES ☐ NO If NO, what language is spoken at home:
How did you hear about Redkite? ☐Hospital ☐Google ☐Coles ☐Friend ☐TV/Print ad ☐Social media ☐Other
If other, please specify: Click here to enter text.
Did the YP/family receive an AYA or Red bag at/around diagnosis? ☐ YES ☐ NO
If ‘yes’ did the YP/family use the $50 Coles voucher provided in the AYA or Red bag? ☐ YES ☐ NO
IF DIAGNOSED YOUNG PERSON IS OVER 18YRS, AND IS NOT THE PRIMARY APPLICANT PLEASE
PROVIDE THEIR DETAILS BELOW.
Address details: ☐ As above ☐ Different
Street: Click here to enter text.
Suburb: Click here to enter text. State: Choose an item. Postcode: Click here to enter text.
Email: Click here to enter text.
Mobile: Click here to enter text. Home phone: Click here to enter text.
Do you identify as being of Aboriginal and/or Torres Strait Islander origin?
NB:Redkite is capturing this demographic data to inform future program development and service provision in becoming a culturally responsive organisation – your answer will not affect the outcome of this application
☐ NO ☐ YES – Aboriginal ☐ YES – Torres Strait Islander ☐ YES – Both Aboriginal and Torres Strait Islander
SECTION 3: SUPPORTING INFORMATION
Please provide a description of:

the young person’s or family’s background and structure

Click here to enter text.

the financial impact of the cancer experience & how this is beyond their current capacity to manage financially

Click here to enter text.

what other options have been considered to manage the finances

Click here to enter text.
Has the YP/family received or applied for any government travel/accommodation reimbursements?
☐ YES ☐ NO If ‘yes’ please provide details below:
Click here to enter text.
Is the YP/family receivingor have they applied for anyCentrelink benefits such as Carers payment, Carers allowance, New Start Allowance, Pension, Disability Pension, Sickness Benefit, Rental Assistance or Youth allowance?
☐ YES ☐ NO If ‘yes’ please provide details below:
Click here to enter text.
Has the YP/family applied for financial assistance from any other organisations (eg. Cancer Council, Leukemia Foundation, Kids with Cancer, etc)?
☐ YES ☐ NO If ‘yes’ please provide details below:
Click here to enter text.

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: 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: Choose an item. Total amount of all bills $

Bill 1: / Amount: $ / Item:
BPAY / Biller Code: / Ref No:
Direct Transfer / a/c Name: / BSB: / a/c No:
Bill 2: / Amount: $ / Item:
BPAY / Biller Code: / Ref No:
Direct Transfer / a/c Name: / BSB: / a/c No:
Bill 3: / Amount: $ / Item:
BPAY / Biller Code: / Ref No:
Direct Transfer / a/c Name: / BSB: / a/c No:

VOUCHERS–recommended $200 combined total per application.

Food: Choose an item. Petrol: Choose an item.

☐ Vouchers to be sent to Social Worker (preferred by Redkite)

☐ Vouchers to be posted to family at the following address (if different to the address listed above):

Street: Click here to enter text.

Suburb: Click here to enter text. State: Choose an item. Postcode: Click here to enter text.

Version 4 Last updated 27October 2016