Fitness Equipment Application Form

FITNESS EQUIPMENT APPLICATION FORM
We understand that not all of our members like going to a gym, or live close by to one. If you would prefer to exercise at home we can provide you with up to $750pa towards a piece of fitness equipment. This can include an exercise or road bike, basketball or netball ring, trampoline, treadmill or something else that you know you will use.

Eligibility:
- Membership of CFT must be current;
- Available to all adults and children with CF.
Entitlement:
- A combined total of up to $750 each calendar year per member for this and the gym membership subsidy (i.e. both cannot be claimed in the same year for a total of more than $750).
- We can reimburse you or pay the invoice directly. Whatever works best for you.
Process:

1. Complete this online form;

2. Let us know if you have paid the invoice, or you would like us to pay it. We will just need proof of purchase for the item and its specifications.

3. CFT reserves the right not to fund requests for items not aligned with the intent of the CF Fitness Equipment policy.

5. CFT will endeavour to process your application within 7-10 days (subject to staff availability).
Name of person who will use the equipment *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Email*

Confirmation Emailexample@example.com
Mobile Number*
Please let us know what you need from us: *
Details of person completing this form (if different from above)

Name

Street Address Line 2

Relationship

Mobile Number
We would love to know more about the reason you have picked this item of fitness equipment. What benefits do you think it will provide you with? *
DETAILS OF EQUIPMENT REQUESTED*
Please upload a photo of any receipts if you have asked for a reimbursement.

Cancelof
BANK ACCOUNT DETAILS

Please provide the bank account details for any reimbursements.
BSB
Account Number
Bank account holder
Name
DECLARATION

I declare that all information I have provided to Cystic Fibrosis Tasmania is true and accurate. I understand if it is found that I have knowingly provided false or inaccurate information I may no longer be eligible to be a member, or receive any or all of the services and benefits provided by Cystic Fibrosis Tasmania.
E-Signature Name*
Date*

DayMonthYear
Date
Should be Empty:

FITNESS EQUIPMENT APPLICATION FORM

BANK ACCOUNT DETAILS