Fitness Equipment Application Form

FITNESS EQUIPMENT APPLICATION FORM
CFT recognises that physical activity is an important part of keeping airways clear, contributes to improved physical and mental health and wellbeing and improves quality of life.

We understand that not all of our members like going to a gym or live near one. If you prefer to exercise at home or outdoors, we can provide you with assistance of up to $750 once every two years for a piece of fitness equipment. This can include (but is not limited to) an exercise or road bike, basketball or netball ring, trampoline, treadmill or something else you know you will use.

Eligibility:
- Membership of CFT must be current;
- Available to all adults and children with CF.
Entitlement:
- Up to $750 for a piece of fitness equipment every two years.
- Members cannot claim from this policy and the Gym membership policy in the same year.
- CFT staff may consult Allied Health Professionals to ensure the suitability of the equipment for the person with CF from a health and age perspective
Process:

1. Complete this online form;

2. If you would like reimbursement for an item, you must seek approval from CFT before its purchase. This ensures the item is suitable for the person with CF and meets the intention of this program. Failure to do so may result in the claim not being paid.

2. Let us know if you have paid the invoice or if you would like us to pay it.

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? *
This information is important to us so that we can demonstrate the value of the program we are providing.
DETAILS OF EQUIPMENT REQUESTED*
Please upload a photo of the item

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

CFT recognises that physical activity is an important part of keeping airways clear, contributes to improved physical and mental health and wellbeing and improves quality of life.

BANK ACCOUNT DETAILS