ALL sections of the form must be completed IN FULL.
Incomplete forms will not be considered for assistance but referred to the applicant for completion.
All information in the form will be treated as confidential.
This application has been completed by:
APPLICANT DETAILS
Is the applicant Aboriginal or Torres Strait Islander origin?
Is the applicant an Australian citizen?
Is English the applicants first language?
Does the applicant have private health insurance?
Does the applicant have access to Medicare benefits?
Does the applicant have income protection?
Income
Relevant cards held
In relation to lodging – Please select
REFEREES


To assist Midwest Charity Begins at Home Inc to make a decision as quickly as possible, we require contact details for three referees who can verify the information provided. The first referee must be your treating medical practitioner.


Please advise these referees to expect contact from us to discuss your circumstances and needs.
Please note: Midwest Charity Begins at Home committee reserves the right to make such enquiries as we consider appropriate in the assessment of your application and may contact other than those nominated.
Please confirm below:
Further direct contact
I accept that a member of the MWCBAH committee will call me to obtain further information or supporting documentation in regard to this application and I agree that I will provide as much information or documentation as requested / necessary.
Privacy
I agree to keep the sum of funds confidential as this helps respect all our recipients both past and present, including in all media interviews.
Promotional Endorsement (if application successful)
I authorize MWCBAH to use any of the information provided in my application for promotional purposes (name withheld unless specific client consent sought).
I certify that I have the consent of ‘the applicant’ in completing this application.
I certify that I have the consent of ‘the applicant’ in completing this application.
I agree to provide a photo opportunity to MWCBAH at the time of the handover of the benefit
I agree to provide a photo opportunity to MWCBAH at the time of the handover of the benefit
I am a local resident / member of the Midwest region
I am a local resident / member of the Midwest region
I understand that the recipient release from and indemnifies the Midwest Charity Begins at Home Inc committee against, all liability that may arise from unforeseen circumstances. The committee’s decision will be final and cannot be contested. No correspondence will be entered. The committee reserve the right to limit entry or amend conditions if considered necessary, without notice.
I understand that the recipient release from and indemnifies the Midwest Charity Begins at Home Inc committee against, all liability that may arise from unforeseen circumstances. The committee’s decision will be final and cannot be contested. No correspondence will be entered. The committee reserve the right to limit entry or amend conditions if considered necessary, without notice.
Declaration of the Applicant

I certify that all of the information given in this application is to the best of my knowledge and belief, correct and that I am the applicant / I am acting on behalf of the applicant.
If the applicant is under 18 years of age this application must be signed below by the applicant’s parent or guardian.
All applications will be reviewed in a timely manner at the discretion of the committee.
PLEASE NOTE: An original signature(s) is required on this document.
Return to: info@charitybeginsathome.org.au or PO Box 1683, Geraldton WA 6531