The Wilson Home Trust

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Emergency Grant Application Form

APPLICANT’S DETAILS:

NAME OF PERSON FILLING OUT THE FORM

First Name (Applicant) *

Surname (Applicant) *

Home Phone

Mobile *

Email (Applicant) *

Postal Address *

Postcode *

Relationship to Child *

PARENT / CAREGIVER DETAILS

IF DIFFERENT FROM ABOVE

First Name (Parent/Caregiver)

Surname (Parent/Caregiver)

Home Phone

Mobile

Postal Address

Postcode

Email (Parent/Caregiver)

CHILD’S DETAILS

First Name (Child) *

Surname (Child) *

Address *

Postcode

Date of Birth *

Ethnicity *

Diagnosis *

Please describe the physical disability that relates to the diagnosis above *

How many people are you supporting in your household? – include children and extended family *

Further Details

Is the child a New Zealand Citizen or Permanent Resident? *

Yes

Has the child received funding from the Wilson Home Trust before? *

Yes

Unsure

If yes, please provide details of how much and when

If this is the first time you are applying for a Wilson Home Trust Grant, how did you hear about us?

Health Professional – e.g. GP, OT, Paediatrician, etc

School

Recommended by a friend or colleague

Social Media

Search Engine – e.g. Google Chrome, etc

I permit The Wilson Home Trust to explore alternative funding options for this application *

Yes

Emergency Grant Application Form

Click Submit to finish.

This form was created by The Wilson Home Trust

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