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Assistance Application Form
All Waiheke families whose child is 18 years or younger and has a health condition are eligible to apply to the Jassy Dean Trust.
Child's first name *
Your answer
Child's last name *
Your answer
Child's date of birth *
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DD
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YYYY
Parent/Caregiver first name(s) *
Your answer
Parent/Caregiver last name(s) *
Your answer
Phone *
Your answer
Email address *
Your answer
Home address *
Your answer
Child's health condition *
Please provide a short description of your child's diagnosis or health condition
Your answer
Has your child's condition been diagnosed by a doctor or specialist? *
Doctor's details
Please provide the details of the doctor or specialist currently treating your child
Your answer
Assistance requested *
Please provide a short description of the support you are seeing from the Jassy Dean Trust
Your answer
Funding requested *
Please provide the cost of each item of support requested (eg cost of treatment per session)
Your answer
Do you require ferry tickets?
Ferry tickets may be requested for your child's health appointment in town. We appreciate the support of Fullers and Sealink.
Date of appointment
MM
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DD
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YYYY
Reason for appointment
Your answer
Details of payment
Please provide the name of the agency providing treatment and contact details for payment. Otherwise please provide bank account details if payment will be directed to parent/caregiver .
Your answer
Other support
Please provide brief details of other support being accessed for your child, if applicable
Your answer
Other relevant information
Please provide any other information to help us understand your child's situation, if applicable
Your answer
Name
Provide the name of the person completing this application form, if different from parent/caregiver
Your answer
Email address
Provide the email of the person completing this application form, if different from parent/caregiver
Your answer
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