Application For Support

Please complete the form below so that we can find out a bit more about you and your caring role. We’ll contact your shortly with the next steps!
Young Carer Full Name*

First NameLast Name
Birthdate*

DayMonthYear
Date
MaleFemaleTransgenderDiverseNon-BinaryPrefer not to say
Address*

Street Address

Street Address Line 2

CityState

PostcodeCountry
I am LGBTQIA+I am a RefugeeI am an Asylum SeekerI have a disability/disabilitiesOther
I am Aboriginal or Torres Straits Islander
Yes
Primary Language Spoken
12345 or more
Sibling (Brother)Sibling (Sister)Carer for parent (mother)Carer for parent (father)Carer for grandparentPartnerOther family memberNon-family
Physical disabilityIntellectual disabilityMental HealthAddictionNeurodivergentAutism Spectrum DisorderCancerSerious injuryChronic illnessDegenerative DisorderGlobal Developmental DelayGenetic DisorderAcquired Brain InjuryFrailty/Old AgeCarer of siblings due to parent unavailabilityOther
Emotional support and companionshipHousehold tasks (eg: cooking/cleaning/laundry)Administering medicationBathing and hygieneCommunicating on behalf of the care recipient (eg: for care recipients who speak a language other than English, or who are deaf, have a speech disorder, or are unable to write/type etc)Financial supportMedical care (eg: arranging appointments/ensuring therapy treatments are followed etc)Mobility assistance (eg: transferring from bed to chair, or assisting with walking etc)Other
Education eg: missing days of school, difficulty focusing, lack of support from teachers etcEmployment eg: reduced hours of work, inability to commit to set hours, cancelling shifts etcMental health and wellbeing eg: stress or anxiety caused by caring role, or having an unwell family member, feelings of isolation, or stigma associated with being a Young Carer etcSocialising eg: unable to engage in outside of school activities, difficulty making friends or having friends over etcNot applicable / does not impact meI prefer not to sayOther
Yes
Which school / tertiary institution / homeschool are you currently enrolled in?
Services Australia / Centrelink payment (including Carer Allowance, Youth Allowance, Disability Support Pension etc)NDISCarer GatewayYoung Carer BursaryI prefer not to sayNo
Referral from schoolWord of MouthSearch engine (Google etc)Social MediaEventA poster or flyerNews articleI prefer not to sayAnother Young CarerOther
Parent / Guardian Name*

First NameLast Name
Relationship To Young Carer*
Parent Guardian Mobile Phone Number or Young Carer's if over 18*
Please enter a valid phone number.Format: (0000) 000-000.
Parent Guardian Email or Young Carer's if over 18*
example@example.com
Preferred Contact
Yes
Please Share Your Name, Organisation and Contact Details:
Permissions & Approvals

Our Privacy Policy explains what we do with this information, how it is handled, how it may be shared, how to access or correct it and our procedure for complaints.

I agree to the following:
- Receiving correspondence from Little Dreamers
- No promises have been made to me by Little Dreamers, regarding my Dream Experience
- All Dream Experience requests are at the discretion of Little Dreamers, and must meet all current guidelines.
- I consent to the collection, use and disclosure of personal information in line with the Privacy Policy
- Where I have provided information about another individual, I declare that the individual has been made aware of that fact and of the contents of the Privacy Policy.
Yes, I agree
Should be Empty:

Permissions & Approvals