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iPad Application Form
Step 2 – Application
Please complete all required fields below for us to process your application.
Applicants details
Applicants name
*
Name of the individual requiring the iPad.
First
Last
Date of birth
*
Date Format: DD slash MM slash YYYY
Age
*
Parent / guardian details
Parent / guardian name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postcode
Mobile number
Home number
Email
Is the applicant funded by NDIS?
*
yes
no
NDIS Plan Number
*
Do you (as parent or guardian) have a current Health Care Card or Pension Card?
*
Yes
No
Please provide your CRN number
*
About your diagnosis
Does your child have a DIAGNOSED Autism Spectrum Disorder or an Intellectual Disability?
*
Yes
No
What is their diagnosis?
Date of diagnosis
*
Date Format: DD slash MM slash YYYY
Who made the Diagnosis?
*
Paediatrician
Psychologist
PsychIatrist
Physician details
*
Dr.
Prof.
Mr.
Mrs.
Miss
Ms.
Rev.
Prefix
First
Last
Physician contact number
*
Physician Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Document uploads
Please upload a copy of your valid health care card
*
Drop files here or
Please upload a copy of your diagnosis
*
Drop files here or
Please upload a signed copy of the Medical Release Authorisation form
*
Drop files here or
