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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
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*
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

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