AHLTA EMERGENCY FINANCIAL ASSISTANCE FORM

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Cc: president@ahlta.com.au

Please use this form if you would like to apply for the $500 Emergency Grant which is available through AHLTA. Please read the Terms and Conditions below before applying.

Terms and Conditions of AHLTA Emergency Grant

AHLTA is here to support and assist pre- and post-transplant recipients and their families and carers. Often during the workup, shortly after transplant and when an unexpected event happens, patients need a financial boost. This grant is for use by patients, carers and families to assist with day-to-day living costs. This grant is subject to Social Worker endorsement.

AHLTA, in consultation with the Transplant Social Work Department can offer the following:

$500 towards day-to-day expenses

CONDITIONS:
You must reside in Australia and be a member of AHLTA.
There is a limit of one application per person/family.
Applications are subject to your Transplant’s Social Work Department endorsement.
AHLTA reserves the right to refuse the application if in receipt of other fundraising in the last 12 months.
AHLTA reserves the right to decline applications even if the above conditions are met.

Please complete the application form below. If you have more questions please contact the president at president@ahlta.com.au

You can then apply for our Financial Assistance Program ($1,000) after 6 months if you are still experiencing financial hardship.

Title *

First Name *

Surname *

Date of Birth

YYYY

Address *

Telephone Number *

Please describe in detail your medical situation including type of transplant and transplant hospital: *

Why are you seeking financial assistance from AHLTA?: *

What benefits are you currently receiving? *

Go Fund Me or similar fundraiser

DSP

NDIS

Aged Care

Health Care Card

Newstart or Jobseeker

Carers Allowance

Veterans Affairs

No Government Benefits

Other:

I understand that all applications are assessed by the AHLTA President and Treasurer on a case by case basis and that acceptance of my application is not guaranteed. This Application will be forwarded to the Social Work Department for endorsement. Please sign name below: *

Date Application Submitted *

YYYY

Approved by Social Work

Yes

Clear selection

Date Approved

YYYY

Approved by President

Date approved

YYYY

Submit

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