Wizzybug Loan Scheme Application

BEFORE STARTING YOUR APPLICATION

Please note: Our average waiting time between application and Wizzybug appointment is 16 weeks. We are experiencing a high volume of applications at present, and this may mean there will be a longer wait than usual before we can respond to your application, but you should still receive your Wizzybug within 16 weeks of applying. Thank you for your patience and understanding.

We welcome applications from families across the UK, we currently have delivery sites in Leeds and Bath. This means that your child may need to travel long distances for their Wizzybug Handover Appointment. Please ensure that you carefully consider any medical risks associated with travel and take advice from your health professional if in doubt.

The safe fitting of Wizzybug relies on the child's size and sitting ability. We usually find children aged from 14 months to 4/5 years are best suited.

Please read the User Requirements and How to Measure Your Child documents on our website to ensure Wizzybug is suitable. You must have your child's measurements, weight and diagnosis information to complete this application.

Where possible, we recommend that you ask your child’s clinician to support you in completing this application.

I have read the User Requirements and How to Measure Your Child documents

Yes

In this section, we will take some basic details regarding:

The child who will be using the Wizzybug
The Parent / Guardian
Your therapist (if applicable)

CHILD WHO WILL BE USING WIZZYBUG

First Name

Last Name

Date of Birth

Sex

PARENT / GUARDIAN

First Name

Last Name

Email Address

I give permission for my email address to be added to Designability's mailing list so I may be contacted with Wizzybug news and events.

YesNo

Address Line 1

Address Line 2

City

County

Postcode

Primary Contact Telephone Number

Please enter without any spaces

Are you able to provide Child Therapist details now

YesNo

CHILD'S THERAPIST (IF APPLICABLE)

First Name

Last Name

Email Address

Company Name

Occupation

Website

Daytime Telephone Number

Mobile Number

Work Email Address

Full Time or School Term Only

ABOUT THE CHILD

BODY MEASUREMENTS (IN SITTING)

Please refer to the User Requirements and How To Measure Your Child documents before completing this section.

(Note: If the measurements of your child are currently less than the minimum allowed, please apply to us again as soon as your child reaches the required minimum measurements)

Please complete the measurements, referring to the image above if needed.

A: Hip width (at widest point in sitting)

0 - 24.5 cm

B: Back of hips to back of knee (seat depth)

18 - 28 cm

C: Seat to top of shoulder (back height)

26 - 38 cm

D: Heel to back of knee (lower leg length)

18 - 30 cm

E: Weight

0 - 18 kg

*your child must be 18kg or less at the time you apply but they are able to use Wizzybug until they are 20kg

Page 4

DIAGNOSIS

Please give a summary of the child's diagnosis

Include information about any recent hospital admissions and surgeries

Other relevant information that may affect driving, sitting or travel to appointment

Add relevant information regarding: vision, hearing, non-oral feeding, seizures, choking, aspiration

List any Medical Devices used and how often

e.g. oxygen, Bipap, Cpap, suctioning, NG tube etc.

SEATING CONSIDERATIONS

In relation to the headings below, please describe any relevant aspects such as contractures, muscle weakness, dislocation, tone, shortened limbs etc. that may affect sitting in the Wizzybug.

Hip / Pelvis

Spine / Trunk

Head Control

Please describe equipment currently used

e.g. mobility aids, specialist head support, specialist seating, orthotic supports, brace, lycra suit, sleep system

Current level of mobility / how does your child move around?

HAND, ARM & SHOULDER FUNCTION

Please describe the following:

Fine motor skills and coordination

Limitations to using a joystick

e.g. range of movement / reach, tone, grasp & release, contractures, muscle strength

Dominant hand (for joystick positioning)

COGNITION

Level of understanding

e.g. cause and effect, following simple instructions

Communication

SECTION 2 - WIZZYBUG APPOINTMENT

Our headquarters are in Bath, however we have a regional centre in Leeds operated by a partner organisation.

By selecting one of these sites, you consent to us sharing your data in accordance with our Privacy Notice. Further information on Designability’s, and our Regional Centres’ policies regarding Data Protection, Data Retention Schedules and information sharing, can be found on our website

Please select a preferred location for the Wizzybug appointment.

Preferred location for Wizzybug appointment

I agree to the relevant data being shared with the Regional Centre selected above

Yes

I agree to adhere to the Health and Safety requirements (which will be shared via email before the appointment)

Yes

HOW DID YOU HEAR ABOUT THE WIZZYBUG LOAN SCHEME?

Please give website address

Which social media channel?

Please give therapist's name and profession

Please give the name of the exhibition

Please give the name of the organisation

Please give the name of the publication

Please describe

ACCESS FUND

Wizzybug is free to all families.

For support to cover the cost of attending your Wizzybug appointment, you can apply to the Access Fund.

Please select whether you wish to be considered for the Access Fund.

YesNo

Media Consent

Please help us to tell other families about the Wizzybug Loan Scheme by sharing your experiences.

Photos, videos and stories of children using their Wizzybugs helps us to raise awareness to reach more families who could benefit.

Real life stories also encourage people to donate, so that we can continue to loan Wizzybugs free of charge.

You can see the kinds of positive stories on our social media channels where we share regular Wizzybug stories.

I am happy to be contacted by Designability's marketing team with requests for photos or testimonials.

YesNo

Any photos / videos / testimonials I share with Designability may be used for the following purposes:

Raising awareness of our work on printed materialsRaising awareness of our work online*Fundraising for our work (in print and online*)Providing content to other organisations involved in our work

*Online will include websites, social media and electronic mailings.

May we use your child's first name, or would you prefer no use of their name?

First nameNo use of name

EQUALITY, DIVERSITY AND INCLUSION

This is an optional section, and will only ever be used for monitoring purposes.

The data will NOT be used in connection to your Wizzybug or Access Fund application.

ABOUT YOUR CHILD

Nationality

Ethnic Origin

Please Specify

ABOUT YOUR FAMILY - DISABILITY

Disability is defined by the Equality Act 2010 as a person who has a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-today activities.

Do any of your child’s primary care-givers have a disability as defined by the Equality Act 2010?

Please give details

ABOUT YOUR FAMILY - FINANCIAL CIRCUMSTANCES