Application For Assistance v2

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Instructions

1. Please fill in the information below.
2. An item marked with * is needed.
3. Please draw your signature at the bottom of the screen.
4. Click on “Send Application” once you are ready.
5. You will be redirected to a confirmation page once the application has been sent to us.

Section A: Type of Assistance

(if you need to apply for more than one type of assistance please fill out a separate application form each)

Please select one of the following:*(Required)

Hardship

Old People’s Fund

Sports

Funeral Travel

Education

Carer

Medical

SECTION B: Personal Details

First Name*(Required)

Last Name*(Required)

Date of Birth*(Required)

DD slash MM slash YYYY

Phone*(Required)

Registered home address

Street Address*(Required)

Suburb*(Required)

State*(Required)

Postcode*(Required)

SECTION C: Application for a child

Is this application for a child?

Please fill in a separate form for another child.

Yes

Child's Full Name*(Required)

Date of birth*(Required)

DD slash MM slash YYYY

Child's current school year?*(Required)

For example, if your child is studying in Year 7, type in “Year 7”.

SECTION D: Medical Assistance

Please provide the following information & documents for assistance relating to Medical:

A letter from the medical professional or social support worker

Letter from the medical professional or social support worker

Drop files here or

Max. file size: 8 MB.

Accepted file types: jpg, gif, png, pdf, Max. file size: 8MB.
You would also be able to take a photo of the document using your phone’s camera.

Date of the appointment:

DD slash MM slash YYYY

SECTION E: Carer’s Assistance

Please provide the following document:

A letter from the medical professional / social support worker

Letter from the medical professional / social support worker

Drop files here or

Max. file size: 100 MB.

Accepted file types: jpg, gif, png, pdf, Max. file size: 8MB.
You would also be able to take a photo of the document using your phone’s camera.

Date of the appointment:

DD slash MM slash YYYY

Name of the Patient

Relationship to the Patient

SECTION F: Sports Assistance

Please provide the following documents for assistance relating to Sports:

Completed registration of the sports event, lessons or course

A support letter from the sports institution

Tax Invoice or Quote

Supporting Documents

Drop files here or

Max. file size: 8 MB.

Accepted file types: jpg, gif, png, pdf, Max. file size: 8MB.
You would also be able to take a photo of the document using your phone’s camera.

SECTION G: Education Assistance

Please provide one of the following documents:

Completed registration of the event, lesson or course

An enrolment letter

Tax Invoice or Quote

Supporting Documents

Drop files here or

Max. file size: 100 MB.

Accepted file types: jpg, gif, png, pdf, Max. file size: 8MB.
You would also be able to take a photo of the document using your phone’s camera.

SECTION H: Expenses Requested

Please make sure you press ‘+’ icon when adding additional expense items.

Expenses Requested(Required)

Item*

Store/Supplier Name*

Amount requested?*

Click on “+” to add more lines. If you have requested for vouchers, please specify, e.g. Woolworths, Coles.

SECTION I: Why do you need help?

(What has happened recently that has caused you to ask for help?)*(Required)

Please provide any other supporting documents that may be relevant.

Drop files here or

Max. file size: 100 MB.

Accepted file types: jpg, gif, png, pdf, Max. file size: 8MB.
You would also be able to take a photo of the document using your phone’s camera.

If your application relates to attending a funeral, please provide a copy of the funeral notice.

SECTION J: Declaration

Declaration(Required)

I declare that the above information is true.*

Signature*(Required)

TIP: You can draw your signature in the box below.

CONTACT US

Port Hedland: 08 9173 1500
Perth: 08 6163 0246
Email: reception@njamal.org.au

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Acknowledgement of Country

Njamal People’s Trust acknowledges the Traditional Custodians of country throughout Australia and recognises their continuing connection to land, waters and community. We pay our respects to them and their cultures and to Elders both past, present and extend this respect to our future generations of leaders.