CF Healthy You Application Form

CF HEALTHY YOU APPICATION FORM
We know that many things can contribute to your physical and mental well-being. We also know they are different for each person. CF Healthy You lets you choose something that will enrich your life in some way. It could be that your mental health benefits from relaxing by reading a book. You may want to get some life coaching or even just go and have a massage. CF Healthy You is intended to cover items that you can't get elsewhere. For example, if you'd like a night out, we'd encourage you to use your Little Day Out entitlement. We can pay Sports Registration fees through CF Sports, but if you need new sports shoes or clothing then CF Healthy You can provide them. It's entirely up to you.

Eligibility:
- Membership of CFT must be current;
- Available to all adults and children with CF.
Entitlement:
- Up to $250 each calendar year per member.
- You may select vouchers from different businesses up to the limit of your annual entitlement.
- We can either purchase vouchers for you from one or more businesses (totalling $250 pa) such as Rebel Sports, or if you purchase an item we can reimburse up to the amount you are entitled to.
Process:

1. Complete this online form;

2. If your request is for less than $250, you can put in another request before the end of the calendar year for the balance;

3. If you have purchased something already and you would like to claim it as a reimbursement, please attach a copy of the invoice (dated within this calendar year) as proof of purchase. Without this, we cannot provide reimbursement.

4. CFT reserves the right not to fund requests for items not aligned with the CF Healthy You program objective. A copy of the policy can be found here.

5. CFT will endeavour to process your application within 7-10 days (subject to staff availability).
Name of CF Healthy You Recipient*

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
Please let us know how you think the item(s) you would like will assist your physical or mental health and wellbeing. *
DETAILS OF CF HEALTHY YOU VOUCHERS YOU WOULD LIKE
DETAILS OF CF HEALTHY YOU VOUCHERS YOU WOULD LIKE
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:

CF HEALTHY YOU APPICATION FORM

BANK ACCOUNT DETAILS