Family Support Program Application Form

Personal Information

Name of Applicant(Required)

First Last

Are you completing this application on behalf of someone else?(Required)

If YES, please record their Name:(Required)

First Last

Applicant Address(Required)

Street Address Address Line 2 City State / Province / Region Post Code

Email(Required)

Phone(Required)

Date of Birth(Required)

Age of person with EB(Required)

Type of EB(Required)

Does this individual have access to NDIS funding?(Required)

Which other agencies have you approached to fund this request?(Required)

Please detail any funding you have received from DEBRA Australia in the last two years.(Required)

Application Details

The Applicant is Applying for(Required)

Please tick relevant items

Please describe in detail the item or service you wish to access(Required)

How will this item or service directly impact the person living with EB or their family?(Required)

Treatment/Management of Symptoms

General Comfort or Quality of Life

Ability to Perform Everyday Tasks

Assist with Cost of Living

Supplier 1

**PLEASE NOTE THAT FOR LARGER ITEMS OVER $500, TWO QUOTES WILL BE REQUIRED

Supplier 1 Name(Required)

Supplier 1 Address(Required)

Street Address Address Line 2 City State / Province / Region Post Code

Supplier 1 Quote Cost(Required)

Supplier 1 Quote Attachment

Drop files here or

Max. file size: 20 MB.

Supplier 2

Supplier 2 Name

Supplier 2 Address

Street Address Address Line 2 City State / Province / Region Post Code

Supplier 2 Quote Cost

Supplier 2 Quote Attachment

Drop files here or

Max. file size: 20 MB.

Please note: applicants can expect to receive a response to applications within 10 days

In completing this application for support from the Family Support Program, the applicant acknowledges and affirms that the application is made in good faith, that they require the requested financial support and that funding through other channels has not been possible. The applicant also acknowledges and affirms that the support requested is directly related to the costs or the impact of living with EB.

Please note: if this application is successful, funding will commence from the date specified by the Family Support Committee. I consent and give permission for the National Family Support coordinator to advocate and speak to the Family Support Committee and relevant Health Professionals about my application or health requirements if deemed necessary. I understand that my personal details will be kept confidential and only shared if necessary by DEBRA staff and health professionals.

Please see: Privacy Policy - DEBRA Australia