MBPH FOUNDATION GRANTS

MILDURA BASE PUBLIC HOSPITAL FOUNDATION

The Lucas Foundation was established in 2014 and has previously raised funds to provide comfort and assistance to residents of Sunraysia, suffering financial hardship due to unforeseen circumstances or illness affecting their children. The MBPH Foundation is proud to be continuing the legacy of the Lucas Foundation in supporting families and children under the age of 12 who need to travel to metropolitan areas for medical treatment for extended periods. *if your child is over this age and you feel you fit all of the other criteria please fill out the application form as all applications willbe assessed on a case by case basis

All applications to MBPH Foundation for assistance must be in an amount of no greater than $10,000.

Please complete this Application Form if you feel your child (Potential Beneficiary) will qualify for financial assistance from The Lucas Foundation in accordance with the mandate of MBPH Foundation and the Terms and Conditions set out on page 2 of this Application Form

By submitting this Application Form to MBPH Foundation you, the Applicant, represent that you have read, and agree to be bound by, the Terms and Conditions set out on page 2 of this Application Form

1. As MBPH Foundation provides funding to beneficiaries that are experiencing financial hardship due to sudden illness or unforeseen circumstances, the foundation requires all applicants and potential beneficiaries to provide certain information in order that it can assess each potential beneficiary's circumstances.

2. MBPH Foundation reserves the right to reject any application Form that is not completed in its entirety or does not attach all additional documentation set out on page 9 of this application form. It is the sole responsibility of the applicant to ensure that this application form is completed properly.

Selection Process 1. All applications will be reviewed by the Foundation Committee selection panel. Each application will be assessed on a case by case basis. If after initial assessment, the selection panel determine the applicant meets the criteria they will request the financial section of the application form be completed and forwarded to them in confidence.

2.On the recommendation of the selection panel of the Foundation, in its absolute discretion, will approve payments from the MBPH Foundation Grants Fund on such terms and conditions as it sees fit.

3. Any decision by the selection panel relating to payments from the Foundation Grants Fund is final and no correspondence will be entered into in relation to such payments.

4. It is anticipated that successful applicants will be notified no later than 28 days after a complete application is received.

Privacy 1.MBPH Foundation will comply with the Privacy Act 1988 in relation to any personal information provided to the Foundation in connection with this application. Applicants consent to MBPH Foundation:

a.Collecting personal Information about them and the potential beneficiary for the purpose of the considering whether to provide financial assistance from the Foundation Grants Fund to the potential beneficiary; and

b. Disclosing any information collected in relation to this application to: i. MBPH advisors (including its legal and financial advisors); and ii. The media for the purposes of advertising any grant made by MBPH Foundation.

Should you have any queries regarding a potential beneficiary's eligibility for financial assistance, these Terms and Conditions or completing this application form, please contact MBPH Foundation via email: foundation@mbph.org.au or contact MBPH Foundation Manager Jake Anstey e: janstey@mbph.org.au or m: 0410334015.

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Potential Beneficiary's Details

Please note that all Applications should be complete and submitted by the potential beneficiary's legal guardian.

Name

Child's given name(s)Child's surname

Phone Number

Please enter a valid phone number.

Email

example@example.com

Postal address

Suburb

State

Postcode

Date of birth: / / *Must be under 12 years of age

Applicant Details (Legal Guardian)

Title

Name

First NameLast Name

Mobile

Email

example@example.com

Postal address

Suburb

State

Postcode

Relationship to potential beneficiary:

Age

1) Does the potential beneficiary live in the Sunraysia District. (please circle)?

2) What is the potential beneficiary's current living situation (please circle)?

a) Living at home with both parents/guardians b) Living at home with a single parent/guardian c)Living between two households

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3) If you answered a) b) or c) to Question 2

a)What is the combined weekly income (after tax) of the potential beneficiary and the potential beneficiary's parent(s)/legal guardian(s)?

b)Does the potential beneficiary receive any government benefits (please circle)?

YES

If YES, please provide details

c)Are the potential beneficiary's parent(s)/legal guardian(s) receiving any Government Benefits (please circle)?

NO

If YES, please full provide details of each benefit received and whom it is awarded to (i.e. applicant, applicant's partner)

4) Apart from the potential beneficiary, how many other children live in the household (please include ages)?

5) Are the potential beneficiary's parent(s)/legal guardian(s) entitled to receive a payment of compensation from an insurance or superannuation fund (please circle)?

6) Have you previously applied for funding from MBPH Foundation for this potential beneficiary (please circle)?

YES

NO

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7) Please describe why the potential beneficiary is in need of financial assistance

8)How much financial assistance does the potential beneficiary require from the Foundation to alleviate some of or all of their financial needs?

9) What will the financial assistance be used for?

10) Does the amount requested cover the total cost of what you are seeking funding for?

YES

If NO, what is the total cost of the item you will use the funding towards?

11) Is the potential beneficiary or the potential beneficiary's parent(s)/legal guardian(s) entitled to receive funds from another source, for part of or the entire amount required (please circle)?

YES

NO

If YES, please indicate source(s)

12) If you answered NO to Questions 10 and 11, please give details of how you will fund the remaining amount

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Please provide an explanation of any other present circumstances that give rise to necessitous circumstances or otherwise support this application. Other relevant circumstances which may be taken into consideration include any health circumstances or incapacity which may increase your cost of living, or impending change in employment circumstances

Please provide at least two referees who may be contacted and asked to provide a written reference:

Name

Job Title

Company

Mobile

Email

example@example.com

Name

Job Title

Company

Mobile

Email

example@example.com

I declare that all information supplied in this Application is, to the best of my knowledge and belief, complete and accurate.

By submitting this application to MBPH Foundation I acknowledge that I have read, and agree to be bound by, the Terms and Conditions set out on page 2 of this application form.

Signature

Date

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Please provide the following additional documentation:

1. A copy of the potential beneficiary's birth certificate

2. Photographic evidence as to the Applicant's identity (i.e. a copy of the Applicant's drivers licence)

3. Evidence as to the relationship between the Applicant and the potential beneficiary, if the Applicant is not listed as the potential beneficiary's parent on the potential beneficiary's birth certificate

4. Medical documentation: completed by a recognised medical practitioner, an occupational therapist or allied health practitioner

5. Supporting letter from an allied health practitioner, giving further details regarding the Applicant's circumstances and need for funding

6. If you are applying for equipment or vehicle modifications: An exact quote from the preferred supplier

7. If you are entitled to receive Government Benefits: A copy of your latest statement for ALL benefits received - for ALL members of the household

8. Any other supporting information you believe may be of benefit in assessing this application, such as bank statements

9. If you are to receive funding from other sources, please include confirmation letter(s)

Completed all sections of this application form

Signed Applicant's Declaration

Attached photographic evidence as to the Applicant's identity (i.e. drivers licence)

Attached a copy of the potential beneficiary's birth certificate

Attached a copy of all government benefits statement(s) for all members of the household

Attached evidence as to the relationship between the Applicant and the potential beneficiary

Attached medical documentation and supporting letter(s)

Attached exact quote from preferred supplier of equipment or vehicle modifications

Attached any other supporting information (i.e. funding assistance from other sources)

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MBPH FOUNDATION GRANTS

APPLICATION FOR ASSISTANCE FORM