Region Commissioner/Group Leader Reference
Please complete:
Sections 1), 3) and 4) if the Applicant is an individual, OR
Sections 2), 3) and 4) if the Applicant is a Group or Region
Section 1: Applicant's Details (Individual/Family Claims)
Applicant Name
First Name
Last Name
Membership Number
Address
Street Address
Street Address Line 2
Suburb
State
Post Code
Applicant Email
Applicant Phone Number
Group Name
Information about the applicant, status of the family and the impact of fire and/or drought.
Have you received an Active Kids Rebate voucher?
Yes
No
Outline the level of support you recommend for the applicant.
Qty/$
Uniform voucher (Qty)
Leader Resource voucher (Qty)
Personal equipment voucher (Qty)
Group fees ($)
Special Activity costs ($)
Mental Health training ($)
Would you like to add another individual (from the same family) to this application?
Yes
No
Applicant 2 Name
First Name
Last Name
Applicant 2 Membership Number
Applicant 2 Email
Applicant 2 Phone Number
Group Name
Information about the applicant, status of the family and the impact of fire and/or drought.
Have you received an Active Kids Rebate voucher for Applicant 2?
Yes
No
Outline the level of support you recommend for the applicant.
Qty/$
Uniform voucher (Qty)
Leader Resource voucher (Qty)
Personal equipment voucher (Qty)
Group fees ($)
Special Activity costs ($)
Mental Health training ($)
Would you like to add another individual (from the same family) to this application?
Yes
No
Applicant 3 Name
First Name
Last Name
Applicant 3 Membership Number
Applicant 3 Email
Applicant 3 Phone Number
Group Name
Information about the applicant, status of the family and the impact of fire and/or drought.
Have you received an Active Kids Rebate voucher for Applicant 3?
Yes
No
Outline the level of support you recommend for the applicant.
Qty/$
Uniform voucher (Qty)
Leader Resource voucher (Qty)
Personal equipment voucher (Qty)
Group fees ($)
Special Activity costs ($)
Mental Health training ($)
Section 2: Applicant's Details (Group/Region Claims)
Applicant Name
Information about the Scout Group and the impact of bushfire.
Outline the level of support you recommend for the Group.
Section 3: Supporting Information
Please include below any other information you would like to provide in relation to this application.
Section 4: Form Completed By
Region Commissioner/Group Leader Name
Member Number
Phone Number
Email
example@example.com
Signed
Date
/
Day
/
Month
Year
Date
Do you support the Applicant's application for financial assistance?
Yes
No
Privacy Policy - https://www.nsw.scouts.com.au/members-services/policies-and-resources/policies/
*
I have received a copy of, or am aware of, the Scouts NSW Privacy Policy, and I consent to the information collected on this form to be used in accordance with the rights and obligations set out in that policy. Also, I acknowledge that any third party, about whom information on this form has been provided by me, has been informed of the Association’s collection of their information and that they are aware of the Scouts NSW Privacy Policy. Information collected on this Grant Application will be treated with strict confidentiality and will only be viewed by relevant persons in the Emergency Relief Fund Management Committee.
Submit
Should be Empty: