AV1 Robot Application Form

AV1 Robot Request Form

Complete this form to request an AV1 Robot for your child or young person.
Application Information

We have a limited number of AV1 Robots available to support children and young people who are unable to attend school due to illness.

Eligibility:
- The child or young person must have been diagnosed with, or received active treatment for, cancer in the last 12 months.
- The child or young person should be between 5 and 18 years old and enrolled in primary, secondary or further education.
- The child or young person's education must be expected to be impacted for at least 4 weeks.
Please also consider the following points:
- You will need access to a stable internet connection at home.
- You will need an Apple or Android device that the AV1 Robot app can be loaded on to.
- The school will need wi-fi connectivity and be willing to support the AV1 setup.
- The school will need to agree to integrate AV1 into classroom activities.
- You will need to sign an AV1 loan agreement.
Every application will be given careful consideration and you should receive a response within two weeks of your application being received. Please ensure that you complete all sections of this form as fully as possible, as we are unable to consider incomplete applications.

If your application is successful, we will send you a feedback survey after the first school term with the AV1 Robot. We request that you complete this within two weeks so that we can measure the impact of our services, which will help us to secure funding for future projects so that we can continue helping families like yours.
Eligibility Checker
I confirm that the child or young person I am applying for will be under 18 years old and in full time education.
I confirm that the child or young person I am applying for has received a confirmed cancer diagnosis, or received cancer treatment, in the last 12 months.

About You

Please complete this section about you, the person completing this form.
Your full name

First NameLast Name
What is your relationship to the child or young person you are applying for?
Applicant
Please specify relationship:
Applicant
Your email
example@example.com
Your daytime phone number
Please enter a valid phone number.Format: 00000 000000.
What hospital are you based at?
What charity are you from?
Has your family received support from Lennox Children's Cancer Fund before?
If you know it, please provide your Lennox reference (usually starting with WG).

About The Child or Young Person You Are Applying For

Please complete this section about the primary beneficiary.
Have there been any changes to your child's diagnosis or treatment since you last received support?
Full name

First NameLast Name
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Age
Today's date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
The following questions are for monitoring purposes only.
Nationality
Ethnicity
Please specify ethnicity:
Religion
Please specify religion:
Diagnosis
Type of cancer
Please specify the cancer type:
Date of diagnosis

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Has your child relapsed?
Date of last relapse

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Is your child currently on active treatment?
When did your child complete their treatment

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Primary treatment centre or hospital name
Please upload a medical report or letter from your healthcare professional as evidence of your child's condition.

Cancelof

Family
Have there been any changes to the people living at your address since you last received support?
Parent/guardian 1 - This should be the child's primary carer and the person we will contact regarding this respite break application and any other services we provide.

First NameLast Name
Relationship to child
Please specify relationship to child
Email
example@example.com
Daytime phone number
Please enter a valid phone number.Format: 00000 000000.
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Is there more than one parent/guardian living at this address?
Parent/guardian 2

First NameLast Name
Relationship to child
Parent/guardian 2
Please specify relationship to child
Parent/guardian 2
Email of parent/guardian 2
example@example.com
Daytime phone number of parent/guardian 2
Please enter a valid phone number.Format: 00000 000000.
Please provide details of all siblings and other children living at the same address

School Information
What school year is your child currently in?
When was your child last able to attend school?

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
When do you expect your child to be able to return to school?

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
School Name
School Address

Street Address

Street Address Line 2

CityCounty

Post Code
Has the school already agreed to support AV1 use?
Please upload a letter of support from the school.

Cancelof

Technical Readiness
Do you have a stable internet connection at home?
Do you have access to an Android or Apple device (i.e. mobile or tablet) that the app can be loaded on to?
Does the school have wi-fi connectivity?

Your Journey with Childhood Cancer
Please tell us a little about your current circumstances and how your child's diagnosis has affected your family
Please tell us how an AV1 Robot would support your child's education and wellbeing.

Declaration
By submitting this application, I confirm that the information I have given is correct and true to the best of my knowledge.

To edit your application, click 'Back'.

To submit your application now, click 'Submit'.
Should be Empty:

AV1 Robot Request Form

Eligibility Checker

About You

About The Child or Young Person You Are Applying For

Diagnosis

Family

School Information

Technical Readiness

Your Journey with Childhood Cancer

Page visible to parents/guardians only

Consent and GDPR

Declaration