Please register child with Brainwave before completing this form.

Please contact the admin@brainwave.org.au to check if you are already registered with Brainwave.

Child with neurological condition

Child's First Name

Child's Last Name

Child Date of Birth

Citizenship Status

Child's Neurological Conditions

To select more than one neurological condition please use your command or control key on your keyboard.

Please detail this child's neurological conditions

Parent/Guardian details

Primary Contact First Name

Primary Contact Last Name

Primary Contact Email

Primary Contact Mobile

Please leave no spaces between the numbers

Applicant Declaration

I am the overseeing Hospital/Medical representative and can be contacted to verify information on this form. I have obtained verbal consent to submit the funding application on behalf of the family.

Your First Name

Your Last Name

Your Title

Your Email

Your Phone

please include area code

Funding request

What are you applying for?*

EquipmentTherapy

Please provide details of what you are applying for?

Is the child registered with the NDIS?

Has funding been sought from other sources? Please detail

Amount requested $

Supporting Documentation

Please note that only PDF, .doc and .docx files can be uploaded

Letter of Support

Upload a letter of support from hospital/ medical service representative overseeing the care of the child.

Quote

The quote may be for equipment, therapy or financial assistance.

I am happy to contribute and support a testimonial/personal story regarding this Brainwave Equipment and Therapy funding experience

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