Medical Travel Assistance Application Form

NAME:*
FIRST NAME: MIDDLE NAME: SURNAME:
DATE OF BIRTH:*
ADDRESS:*
STREET: SUBURB: POSTCODE:
EMAIL:*
MOBILE:*
LETTER OF CONFIRMATION OF CRISIS FROM HOSPITAL OR
Please upload your Letter of Confirmation. You can upload a PDF, JPEG or Microsoft Word document.
Drop files here or

Accepted file types: pdf, jpg, doc, docx, Max. file size: 10 MB.
LETTER OF APPOINTMENT FOR CHRONIC ILLNESS TREATMENT
Please upload your Letter of Appoinment. You can upload a PDF, JPEG or Microsoft Word document.
Drop files here or

Accepted file types: pdf, jpg, doc, docx, Max. file size: 10 MB.
On approval of application a registered Gift Card will be issued to the applicant for the use of Travel, Accommodation, Fuel and Food ONLY. All cards are registered to the WCO and monitored by us. By signing below, you acknowledge that you understand the card will only be used for the above purposes and if ANY inappropriate use of the Gift Card is recorded it will result in the applicant losing access to all funding assistance for twelve months.
Application Declaration
I have read and understand the Policy and I declare all information supplied to be true and correct. I agree that my typed name below can be used as a digital representation of my signature to that fact.
TO ACCEPT, TYPE YOUR NAME BELOW*
For any application enquiries please contact the office on 08 9997 3444 or email members@wajarri.com.au

Application Declaration