Individual Grant Form

52 Degree Foundation Individual Grant

Application Form

We provide assistance for the purchase of mobility equipment, communication devices, medical and assistance dogs, as well as essential medical and health equipment to support Victorian children with a medically diagnosed chronic illness or disability. Please read the Individual Grant Guidelines before completing this form.

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Child First Name

Child Last Name

Child Street

Single Line Text

Child Suburb

Child Postcode

Child Date of Birth

Child Gender Identity

Male
Female
Other

What is the child's residency status?

Australian Citizen
Permanent Resident
Temporary Resident
Refugee
Asylum Seeker
Other

Child Main Language Spoken at Home

Enrolled in School

Name of school child attends/will attend

Is child of Aboriginal or Torres Strait Islander heritage

Grant Criteria

Criteria Applying Under

Financial Hardship
Disability/Chronic Illness

Information about the child's diagnosis or disadvantage or information about the types of special needs or disadvantage catered for

Type of disability

Physical
Intellectual/Cognitive
Sensory/Neurodivergent
Psychological/Social/Emotional
Other

About the disadvantage

Additional Information to support your application

Are you applying for an Assistance Dog

Assistance Dog

Who is your registered Assistance Dog provider?

Assistance Dogs Australia
Smart Pups
Dogs for Life (CSTDA)
Therapy Animals Australia
Righteous Pups

Date accepted by assistance dog provider

Is your house and yard suitable for an Assistance Dog (including a safe toileting area, strong fencing and indoor access)?

Yes
No
Other

Please explain how Suitable your property is for an Assistance Dog.

Are you financially able to provide the upkeep costs for your Assistance Dog, including food and veterinary care, for 10-15 years?

Yes
No
Other

Are you willing to undertake the ongoing training, accreditation, socialization and care the Assistance Dog will require?

Yes
No
Other

Grant Purpose

Equipment Required

What are you applying for?

How many years will item be used for?

Total Cost of the Equipment (ex GST)

Able to make financial contributions?

How much are you requesting from 52 Degree Foundation Victoria?

Can you provide any further details about the equipment and its usage. (maximum 250 words)

Does the child have an NDIS plan?

Yes
Waiting for Approval
Awaiting planning meeting
Not eligible for NDIS

Requested item applied for with NDIS?

Declined - NDIS do not fund
Declined - lack of funding/not in plan
Partial funding, requesting gap
Awaiting decision - urgent request

Please Upload NDIS evidence for declined, partial funding or expected waiting period (File size up to 2.5MB allowed)

Quotes

Please provide a minimum of 2 quotes, unless there is only one manufacturer. Quotes must be valid for the entire application process which may be up to 10 weeks after the advertised closing date.

Quote 1 (File size up to 2.5MB allowed)

Quote 2 (File size up to 2.5MB allowed)

Tell us a bit more about how the grant will assist

What are the expected benefits and outcomes if this grant application is approved? (maximum 250 words)

Has the child previously received assistance from 52 Degree Foundation Victoria?

Number of Parent's/Carer's dependants

Ages of Dependants

Parent Carer Details

Who cares for the child?

Mother
Father
Both Parents
Foster/Protection/Emergency/DFFH Care

Parent / Carer One

Does Parent / Carer One live with this Child?

First Name

Last Name

Mobile

Email *

Street

Suburb

Postcode

Current Housing Situation

Rent
Mortgage
Own Home
Government Assisted Housing

Relationship to child

What is your total annual income before tax?

Are you the Parent or someone else?

Who is completing the form today?

Parents
Someone Else

Who is completing this form today?

The person completing this form will be the Primary Contact for this application. All future communications about the application will be sent to the Applying Contact.

Applicant Details

What is your relationship to the child?

Primary Carer (parent/guardian)
Nominated Contact

First Name

Last Name

Organization Name

Job Title

Preferred Email

Personal
Work

Email *

Preferred Phone

Mobile
Work

Phone Number

Street

Suburb

Postcode

About Referees

Who can provide a valid reference?

Only relevant professionals are valid referees. For example, an education referee is a teacher, well-being officer or principal from the school the student attends). Please note that we may contact referees to discuss this application. A valid written reference must be on LETTERHEAD and SIGNED by the referee.

Please obtain a letter (no older than 2 months) from an education support person (i.e. a teacher, well-being officer or Principal from the school the student attends or will attend). Please follow the instructions closely, as this letter is key to a successful application. Applications submitted without or with an incomplete support letter will be declined.

A letter of support on school letterhead and signed by the support person that address the following points:

1. How the student is known to the support person.

2. Is the student expected to remain in education for at least the advertised calendar year?

3. Does the student have a good school attendance record?

4. How the student will benefit from the support.

Referee for students applying under Disability/Chronic illness.

For students applying under Disability/Chronic Illness please provide a letter from a doctor or allied health professional, on letterhead, referencing the students disability or chronic illness disagnosis.

If the student is applying for an Accessible Technology item then supply a letter from an allied health professional prescribing the equipment, how it will benefit the student and whether it has been trialled.

Medical/Healthcare/School Referees

Healthcare Professional Referee Details

First Name

Last Name

Office Phone Number

Email *

Organisation/Company

Referee Title/Position

School Referree

First Name

Last Name

Office Phone Number

Referee Title/Position

Referee Primary Email

School

Referee Supporting Documents

Healthcare Professional Reference Letter (File size up to 5MB allowed)

Doctor/Specialist Reference Letter (File size up to 5MB allowed)

School Reference Letter (File size up to 5MB allowed)

Consent & Referral Details

Please note that your answer has no bearing on the outcome of your application.

Your privacy is respected by 52 Degree Foundation. The personal information you provide on this form (including sensitive information about your health) will be used to assess your eligibility. It may be provided to organisations that assist us, or as required or authorised by law, but we will not use any of your sensitive information for marketing purposes, without your prior consent.

If you have any privacy concerns or would like to verify information held about you please contact 52 Degree Foundation Victoria on 03 8698 3900. By ticking below, you confirm that you have read and agree to 52 Degree Foundation’s guidelines.

Submission of this application to 52 Degree Foundation does not expressly mean or imply that 52 Degree Foundation has accepted your application. 52 Degree Foundation is under no obligation, legal or otherwise, to process your application to a successful conclusion. Each application will be determined on its merits, and within 52 Degree Foundation's funding guidelines. 52 Degree Foundation is not liable for any loss or damage whatsoever upon your application being declined.

By forwarding this application to 52 Degree Foundation, you acknowledge that any and all implied terms and conditions or warranties implied by law are excluded.

You acknowledge on making this application that 52 Degree Foundation has not made any representation, or given any promise or undertaking as to the fitness of any equipment or product(s) sought to be supplied to you in pursuant to this application. It is solely for you to determine whether the equipment or product being sought is fit for its purposes. 52 Degree Foundation may arrange for the supply and delivery of equipment or a product, but it is neither the vendor nor the supplier of any equipment or product. Accordingly, 52 Degree Foundation will not be responsible for any direct or consequential loss or damage arising or related in any way to this application or its subject matter.

I consent to 52 Degree Foundation collecting the information provided on this form. I have read and agree to 52 Degree Foundation's guidelines. I understand that if I do not provide the information requested, I may be ineligible to receive assistance from 52 Degree Foundation.

Checkboxes

I consent to 52 Degree Foundation collecting the information provided on this form. I have read and agree to 52 Degree Foundation’s guidelines. I understand that if I do not provide the requested information, I may be ineligible to receive assistance from 52 Degree Foundation.
I/We give consent to 52 Degree Foundation to share this information with its partner in the US, Cerner Charitable Foundation and the Oracle Health Foundation, for the purpose of securing additional funding.
I/We give consent for 52 Degree Foundation to generate publicity through print and electronic media should this application be successful.
I want to receive Grant Notifications.
I want to receive 52 Degree Foundation Heartbeat Newsletter.

Referral

How did you hear about 52 Degree Foundation?

52 Degree Foundation website
Social media
Press
Referee
Word of mouth
School
Other

How long did the app form take to complete?

How easy was the form out of 10? (1 being easy and 10 being difficult).

Do you have any feedback on this application process?

Individual Grant Form

52 Degree Foundation Individual Grant

Application Form

Grant Criteria

Assistance Dog

Grant Purpose

Equipment Required

Quotes

Tell us a bit more about how the grant will assist

Parent Carer Details

Parent / Carer One

Are you the Parent or someone else?

Who is completing this form today?

The person completing this form will be the Primary Contact for this application. All future communications about the application will be sent to the Applying Contact.

Applicant Details

About Referees

Who can provide a valid reference?

Referee for students applying under Disability/Chronic illness.

Medical/Healthcare/School Referees

Healthcare Professional Referee Details

School Referree

Referee Supporting Documents

Consent & Referral Details

Referral

Contact - Australia

Contact - WORLDWIDE

Foundation

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