Empower Fund Application Form

Empower Fund Application

Please read the Guidelines to Applying for a Grant document before filling this form in - it has some pretty important info about the application process, what we will and won’t fund and other stuff to help you get your application right.

Any queries, please contact Bryony.

Once you have submitted your application we will contact you to discuss any items we need clarification on. If your application is approved by our Empower Fund Grants Committee you will be notified in writing.

Please complete the form below & make sure you upload relevant quotes and documentation or you will not be able to submit your application.
Contact Details
Name*

First NameLast Name
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

SuburbState

Postal Code
Email Address*
example@example.com
Phone Number
Are you an individual with a neuromuscular condition?*

YESNO
Please specify your relationship to the person with a neuromuscular condition you are applying for the grant for
Name

First NameLast Name
Date of Birth

DayMonthYear
What type of neuromuscular condition do you (or the person you are applying for) have?*
Grant Details
What type of grant are you applying for?*

Empower GrantHardship Grant
Is the funding you are requesting:*

Under $500$500 or more
Because your item is under $500, you need to upload 1 quote*

Cancelof
Because your item is over $500, you need to upload 2 quotes*

Cancelof
Is the funding going towards medical equipment?

YesNo
Please upload a letter of recommendation from your health professional (eg. physiotherapist or occupational therapist)*

Cancelof
Total Funding Request*
Have you applied for an Empower Grant with us in the last 24 months?*

YesNo
Please give details of the item you are requesting funding for*
What will the benefit of the grant be to the recipient*
Have you applied for funding from other sources for this item?*

YesNo
Please provide details here about other funding sought*
Have you received funding from another source for the same item you are applying for here*

YesNo
a) Name of source
b) Reason why you are seeking further funding for this item
Household Income

Please include all sources of net income & pensions
Name of 1st person receiving household income*
Total monthly income for 1st person*
Name of 2nd person receiving household income
Total monthly income for 2nd person
Total monthly income for household (add both together)*
Household Expenses
Monthly housing costs (rent/mortgage)*
Monthly utilities costs (water/gas/electricity/rates)*
Monthly grocery costs (average)*
Monthly medical expenses*
Monthly education & recreation expenses*
Monthly child care expenses*
Monthly insurance expenses*
Total Monthly Household & Living Expenses*
DECLARATIONS

Neuromuscular WA respects and upholds your right to privacy protection under the National Privacy Principles in regulating how we collect, use, secure, disclose and hold your personal information. Aside from providing information necessary for the grant assessment purposes, Neuromuscular WA will not disclose your information to a third party without your written permission.When a partial grant application is requested and a third-party grant agent is involved, this may be an occasion when we may be required to disclose your information included in the grant application. We may disclose your name, the item you have applied for, and the amount you have requested from Neuromuscular WA. We may also disclose to the third-party grant agent the amount that was successfully allocated to you.
As this document collects personal information, please read our Privacy Policy to understand how we will use and store this information.
Your Privacy*

I understand and accept that it may be necessary as part of the grant assessment process that Neuromuscular WA may disclose certain information to third party grant agents, third parties in relation to confirmation of quotes, or third parties who supplied supporting documentation.
Grant Criteria*

I have read and understood the Neuromuscular WA Empower Fund's Guidelines for Grants and that my application is subject to the grant funding criteria.
True and Correct Declaration*

I declare that the answer I have given in this application and the documents I will provide are true and correct to the best of my knowledge and belief. I declare that I have read and understood the application instructions, declarations and all information related to this application.
Information use acknowledged*

I acknowledge that if my application is successful I allow Neuromuscular WA to use my grant story for promotional purposes.
Signature

Clear
Should be Empty:

Contact Details

Grant Details

Household Income

Household Expenses

DECLARATIONS