Empower Fund Application Form

Empower Fund Application

Please read the Guidelines to Applying for a Grant document before filling this form in - it has some pretty important info about the application process, what we will and won’t fund and other stuff to help you get your application right.

Any queries, please contact Kymberley.

Once you have submitted your application we will contact you to discuss any items we need clarification on. If your application is approved by our Empower Fund Grants Committee you will be notified in writing.
Guidelines to Applying for a Grant*

I confirm I have read the Guidelines to Applying for a Grant (linked above) before proceeding with my application
Please confirm the grant type you are applying for*

Empower Grant (to empower or enrich your life)Hardship Grant (an essential item or service you need)
This is the correct grant for you! Please fill in all questions below and submit before the deadline for your application to be considered.

Please make sure you upload relevant quotes and documentation or you will not be able to submit your application. You can save your progress at the bottom of the form and continue later.
Essential items and services do not meet the grant requirements for the Empower Fund, but are eligible items for a Hardship Grant. Please follow the link below to fill in a Hardship Grant application.

https://form.jotform.com/NeuromuscularWA/hardship-application
Have you received an Empower grant at any time since August 2023? Note: Applicants are eligible to receive an Empower grant once every 24 months. If you were awarded a grant in August 2023 or earlier, you are now eligible to apply again.*

YesNo
You have indicated you are still within the exclusion period of recieving another grant. Please contact Kymberley at kym@neuromuscularwa.org.au if you need to discuss your eligibility.

Contact Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

SuburbState

Postal Code
Email Address*
example@example.com
Phone Number*
Are you an individual with a neuromuscular condition?*

YESNO
Please specify your relationship to the person with a neuromuscular condition you are applying for the grant for*
Name*

First NameLast Name
Date of Birth*

DayMonthYear
What type of neuromuscular condition do you (or the person you are applying for) have?*
How is your daily life currently impacted by your condition?*
Grant Details
Is the funding you are requesting:*

Under $500$500 or more
How many individual items are you applying for? (E.g. flights, accommodation, car hire)
Because your application is for under $500, you need to upload 1 quote for EACH item requested (e.g. flights, accommodation, car hire)
Because your application is for over $500, you need to upload 2 quotes for EACH item requested (e.g. flights, accommodation, car hire)
Upload quote for your FIRST item requested*

Cancelof
Upload first quote for your FIRST item requested*

Cancelof
Upload second quote for your FIRST item requested*

Cancelof
Upload quote for your SECOND item requested*

Cancelof
Upload first quote for your SECOND item requested*

Cancelof
Upload second quote for your SECOND item requested*

Cancelof
Upload quote for your THIRD item requested*

Cancelof
Upload first quote for your THIRD item requested*

Cancelof
Upload second quote for your THIRD item requested*

Cancelof
Upload quote for your FOURTH item requested*

Cancelof
Upload first quote for your FOURTH item requested*

Cancelof
Upload second quote for your FOURTH item requested*

Cancelof
Upload quote for your FIFTH item requested*

Cancelof
Upload first quote for your FIFTH item requested*

Cancelof
Upload second quote for your FIFTH item requested*

Cancelof
Is the funding going towards allied health services or equipment?*

YesNo
Please upload a letter of recommendation from your health professional (eg. physiotherapist or occupational therapist)*

Cancelof
Total Funding Request*
Please give details of the item you are requesting funding for*
What will the benefit of the grant be to the recipient*
Other Funding*

I have an application in progress with another organisation for the same item/serviceI have secured funding from another organisation for the same item/serviceI have not sought or secured funding from another organisation for the same item/service
Please provide details here about other funding sought*
a) Name of source*
b) Reason why you are seeking further funding for this item*
Does the item/service cost more than the amount you are applying for?*

YesNo
How will shortfall be funded?*
DECLARATIONS

Neuromuscular WA respects and upholds your right to privacy protection under the National Privacy Principles in regulating how we collect, use, secure, disclose and hold your personal information. Aside from providing information necessary for the grant assessment purposes, Neuromuscular WA will not disclose your information to a third party without your written permission.When a partial grant application is requested and a third-party grant agent is involved, this may be an occasion when we may be required to disclose your information included in the grant application. We may disclose your name, the item you have applied for, and the amount you have requested from Neuromuscular WA. We may also disclose to the third-party grant agent the amount that was successfully allocated to you.
As this document collects personal information, please read our Privacy Policy to understand how we will use and store this information.
Your Privacy*

I understand and accept that it may be necessary as part of the grant assessment process that Neuromuscular WA may disclose certain information to third party grant agents, third parties in relation to confirmation of quotes, or third parties who supplied supporting documentation.
Grant Criteria*

I have read and understood the Neuromuscular WA Empower Fund's Guidelines for Grants and that my application is subject to the grant funding criteria.
True and Correct Declaration*

I declare that the answer I have given in this application and the documents I will provide are true and correct to the best of my knowledge and belief. I declare that I have read and understood the application instructions, declarations and all information related to this application.
Signature

Clear
Should be Empty:

Contact Details

Grant Details

DECLARATIONS