#GiveBackSG: CPAP / BiPAP Project
We understand that there will be several restrictions in order to qualify for sponsorship and financial assistance, as well as priorities where most of your income goes into. Below is a short form that you can help us fill in honestly so we can learn more about your need and how we can do our best to help. *Application within Singapore only
Name of Applicant
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: 00000000.
Please check the following problems that you encounter: (Check all that apply)
Daytime Sleepiness
Fatigue
Waking up choking / gasping for breath
Morning headaches
Difficulty concentrating
Memory loss
Irritability
Are you diagnosed with any of these medical problem: (Check all that apply)
High blood pressure
Mood disorders / Depression
Coronary artery disease
Stroke
Congestive Heart Failure
Heart Attack
Atrial Fibrillations
Diabetes
Have you seen a doctor & diagnosed with Sleep Apnea?
*
Yes
No
If yes, what is the severity
Please Select
Mild
Moderate
Severe
Did your doctor advise you to use a CPAP / BiPAP?
*
CPAP
BiPAP
No
Have you previously used a CPAP / BiPAP machine?
*
Yes
No
Have you tried applying for projects or support in order to purchase own machine?
*
Yes
No
If yes, what is the reason for not getting support?
Are you currently employed / getting support financially (from family / friends / government / charities)?
*
Yes, employed
Yes, getting support
No
Average / month in SGD$
E.g. $1000 / month
Describe the in and out of your cashflow: (E.g. how many children are you supporting, any support provided to parents / children, medical bills, etc. Please be specific)
I understand that this application is not a guarantee and the machines are previously owned.
*
Agree
I agree that The Air Station may collect, use and disclose my personal data, as provided in this form for marketing purposes. This is in accordance with the Personal Data Protection Act 2017 and Data Protection Policy.
Submit
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