SC Mammography Welfare Grant Application

South Canterbury Mammography Services Trust
WELFARE GRANTS

The South Canterbury Mammography Services Trust is a charitable trust. Our Trustees allocate grants to women living in the South Canterbury region who are experiencing financial hardship due to a breast cancer diagnosis.

TRUST MISSION: Funding Unmet Health Needs for Women in South Canterbury

CRITERIA
1. Applicants must:
  - have been diagnosed with breast cancer within the last three years or a recurrence;
  - be South Canterbury residents;¹ and
  - be in financial hardship due to a breast cancer diagnosis.
2. Grants are available for:
  - products and services that may be required as a result of a breast cancer diagnosis, related surgery and/or cancer treatment (eg. wigs, prosthesis, physiotherapy through Pinc and Steel Trust).
  - a wide range of needs, such as childcare, clothes, household costs (e.g. food, firewood), critical bills or transport.
3. Grants are not available:
  - for alternative therapies; or medications or other treatment costs
  - where the applicant holds an insurance policy that provides cover for the products, services and/or specific need(s) for which the grant is sought.
  - Products, services and/or specific need(s) not related to the applicant's situation of financial hardship due to a breast cancer diagnosis
TERMS AND CONDITIONS
1. Applications must be made on this form.
2. Applications will only be accepted if:
  - All relevant information requested in this form has been provided; and
  - The application has been made on the recommendation of a medical practitioner or other allied health professional.
3. The Trust has the discretion to decline any application.
4. The Trust may approve grants of up to $1,000.
5. The Trust may approve grants of up to $1,500 per applicant for all welfare grant applications made by the applicant within any 3-year period.
6. When approved, grants will be paid by the Trust directly into the applicant’s nominated bank account.
¹ “South Canterbury resident” means a person whose normal place of residence is within the South Canterbury District Health Board area.

HOW TO APPLY

By completing the online form on our website, or by downloading the pdf form from our website and emailing to admin@scmammography.org.nz or posting to South Canterbury Mammography Services Trust, PO Box 163, Timaru.

APPLICATION PROCESS
1. Once we receive your application, we will review the information you have provided and confirm to you that:
  - Your application is complete and will be considered by the Trust; or
  - Your application is incomplete, and the further information that is required.
2. In either case, it may be necessary for the Trust to contact you and/or your medical practitioner/health professional.
3. You will be advised within a month of the Trust’s decision.
4. If your application is successful, the grant approved by the Trust will then be paid into your nominated bank account.
OUR CONFIDENTIALITY DECLARATION

Your completed application will only be viewed by the Trustees of the South Canterbury Mammography Services Trust and the Trust’s Administrator and kept confidential.

Application Form

Part 1: Applicant to Complete
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Applicant Email*
example@example.com
Date of Birth*

DayMonthYear
Date
GP/Practice*
Date of Breast Cancer Diagnosis*

DayMonthYear
How does your financial hardship relate to your breast cancer diagnosis?*
What do you propose to use the grant for? (Please give full details)*
Do you hold a current community services card?*

YesNo
How much are you applying for?*
Do you hold an insurance policy (e.g., medical insurance, trauma cover, income protection cover) that provides cover for the products, services and/or specific need(s) for which a grant is sought?

YesNo
Have you received financial assistance from another source? (e.g. Cancer Society)*

YesNo
If you answered yes to the above question:
How much did you receive?*
Who was it from?*
What was it for?*
Would you like to add any further information?*
Details of your Bank Account for Grant payment (if approved your grant will be direct credited to this account)
Bank Account Name*
Bank Account Number*
Application Date*

DayMonthYear
Date

Application Form

Part 2: Health Professional to Complete
Referring Professional Contact Information
Name*

First NameLast Name
Profession*
Phone Number*
Referrer Email*
example@example.com
In my opinion, as far as I am aware, the financial resources of the applicant and her family are limited, and her diagnosis of breast cancer is likely to result in genuine hardship. (Please confirm)
Should be Empty:

South Canterbury Mammography Services Trust

WELFARE GRANTS

TRUST MISSION: Funding Unmet Health Needs for Women in South Canterbury

CRITERIA

TERMS AND CONDITIONS

HOW TO APPLY

APPLICATION PROCESS

OUR CONFIDENTIALITY DECLARATION

Application Form

Application Form