Little Day Out Application Form

We appreciate that the pressures of living with CF can be challenging. CFT is excited to offer you and your loved ones a "Little Day Out". A fun experience with your loved ones for a little bit of respite from everyday life.

Eligibility:

Membership of CFT must be current;
Available to all adults and children with CF.

Entitlement:

Up to $200 each calendar year in vouchers from a business of your choice. This could include concerts, sporting events, experiences, and restaurant or accommodation vouchers. You are only limited by your imagination!
You may select vouchers from different businesses up to the limit of your entitlement.

Process:

1. Complete this online form;

2. If your request is for under the $200 limit, let us know if you would like some cinema tickets for the balance;

3. If the Little Day Out experience(s) you have selected are more than $200 we will contact you to discuss how we can process this for you.

4. CFT will endeavour to process your application within 5-7 days (subject to staff availability).

Please note that if your tickets are purchased for a specific activity and due to unforeseen circumstances (such as illness) you are unable to attend, please contact the CFT office so that the tickets can be passed onto another member. In this event, however your Little Day Out allocation cannot be credited.

Name of Little Day Out Recipient*

First NameLast Name

DOB of CF Patient

Date

Address*

Street Address

Street Address Line 2

CityState

Post Code

Email*

Confirmation Emailexample@example.com

Mobile Number

Details of person completing this form (if different from above)

Name

Street Address Line 2

Relationship

Mobile Number

DETAILS OF LITTLE DAY OUT EXPERIENCE YOU WOULD LIKE*

DETAILS OF LITTLE DAY OUT EXPERIENCE YOU WOULD LIKE

WOULD YOU LIKE CINEMA VOUCHERS IF YOU HAVE ANY FUNDS LEFT OVER? *

Yes or No

Street Address Line 2

Cinema location

Any special requests ?

While most businesses offer gift vouchers, occasionally some don't. If we are unable to purchase vouchers for the experience you have selected, please provide your bank account details. In these circumstances, if we cannot make other arrangements, we will make a payment to you for the experience. If this occurs, you agree to provide CFT with a copy of the receipt from the activity for their records.

If vouchers are unavailable I agree to provide CFT with a copy of the receipt from our Little Day Out activity when it is undertaken.*

YesNo

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*

Date

LITTLE DAY OUT APPLICATION FORM

We appreciate that the pressures of living with CF can be challenging. CFT is excited to offer you and your loved ones a "Little Day Out". A fun experience with your loved ones for a little bit of respite from everyday life.