Health and Wellbeing Application Form
Head Tenant / Household details
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Postcode
Date of Birth
*
/
Day
/
Month
Year
Date
Current Date
-
Day
-
Month
Year
Date
Age
Gender
*
Please Select
Male
Female
Other
Email
*
example@example.com.au
Phone Number
*
Please enter a valid phone number.
Format: 0000000000.
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2. Eligibility Criteria
Note: All criteria must be met to be eligible for SHEW funding
*
I have been a Pacific Link tenant or household member for more than 6 months
I am an Australian citizen or permanent resident
My rent payments and non-rent payments are up to date
The applicant / child has not received SHEW funding of more than $250 this year
The household has not received SHEW funding of more than $1,000 this year
Are you of Aboriginal or Torres Strait Islander origin?
Aboriginal
Torres Strait islander
Neither
Do you speak a language other than English at home?
Yes
No
Please specify
Do you have a disability or ongoing medical condition?
Yes
No
Prefer not to say
Comments
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Details of tenant applying for funds if different from above
Yes
No
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
-
Day
-
Month
Year
Date
Age
Gender
*
Please Select
Male
Female
Other
Is the child of Aboriginal or Torres Strait Islander origin?
Aboriginal
Torres Strait Islander
Neither
Does the child have a disability or ongoing medical condition?
Yes
No
Prefer not to say
Comments
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SPORT / ACTIVITY INFORMATION
What sport or activity are you applying for? e.g. gymnastics, football, music, art
*
What will funds be for? e.g. uniform, registration, materials
*
How much are you applying for? Maximum of $250 per child
*
If successful, who will funds be paid to? e.g. sports club, store, organisation
*
How will SHEW funds improve the applicants health and wellbeing?
*
Are there any other special circumstances you haven’t mentioned?
Yes
No
If Yes (Please provide details)
Please upload any invoices or documents related to the sport / activity
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APPLICATION DECLARATION
Full name of Head Tenant making this declaration
*
I certify that the personal information provided in this application is correct
*
Yes
No
I give permission for Pacific Link to collect, use and disclose personal details only forthe purpose of assessing the application and administering funds?
*
Yes
No
I would like the applicants name changed in any communications
*
Yes, please change name
No, you can use the applicants first name
How did you find out about the SHEW program?
Website
Newsletter
Staff Member
Email
Other
Do you give consent for PLH to use your photograph for publicity purposes?
Yes
No
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