Family Support Program Application Form

Family Support Application
Reimbursement Application

Family Support Application

Reimbursement Application

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 Post Code

Email(Required)

Phone(Required)
Date of Birth(Required)

Day
Month
Year

Age of person with EB(Required)
Type of EB(Required)
Does this individual have access to NDIS funding?(Required)
Is funding for this request available through any other program e.g. NDIS, Dept of health?(Required)
Have you applied through any other pathway?(Required)
Was funding available?(Required)
If funding wasn’t approved, what is the reason?(Required)
Please detail any funding you have received from DEBRA Australia over $500 or funding which is on-going for support services in the last two years.(Required)
Reimbursement Details
Please complete this section only if seeking reimbursement for goods or services.
Please note: Family Support reimbursements are available upon application for individuals and families experiencing financial hardship related to living with EB. Please review the guidelines, available via the link below, before submitting your application. These guidelines are subject to ongoing review and may change in line with available funding, program requirements, and budget allocations.

Please see: Funding Guidelines - DEBRA Australia
Reimbursement for the following goods or services
Shoes / Socks
Medication prescribed by Medical Specialist / Dermatologists
Hospital admission medical or EB related expenses
Electricity
Linen & Apparel
Psychology / counselling services
Other
Please specify
Reimbursement receipt upload

Drop files here or

Max. file size: 20 MB.

Please sign terms and conditions at the end of this document.
Please note: applicants can expect to receive a response to applications within 10 days
Terms and Conditions(Required)
I agree to the EB Family Support Application Terms and Conditions.
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.
Ongoing Funding Support Terms and Conditions(Required)
I understand that in the case of on-going funding support this application will be reviewed every 6 months and I am required to complete and submit another application form(Required)
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. Funding guidelines are subject to ongoing review and may change in line with available funding and budget allocations.

Please see: Privacy Policy - DEBRA Australia

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Family Support Application

Reimbursement Application

Family Support Application

Personal Information

Application Details

Supplier 1

Supplier 2

Reimbursement Application

Personal Information

Reimbursement Details