Serious Illness and Emergency – Form

Funding to assist Members to attend the bedside of a terminally ill or seriously ill relative (who is a Member) may be available for:

Other Key Factors

Only immediate blood or cultural relatives of the patient can be assisted.
Verification from the hospital or a doctor must be provided – e.g. a letter.
Funding will only be provided if other community or Government funding (e.g. PATS) cannot be obtained.

To apply, submit the form.

You will receive a confirmation email when your application has been received.

SERVICE STANDARDS
If your application is consistent with trust policies and budget you can expect approval within three business days.

Online Application Form

"*" indicates required fields

AM-YAC Member Name*

Phone*

Postal Address*

Contact's name*

Contact's phone number*

Assistance request details?

Attach supporting documents*

Medical – attach your appointment note or letter and your PATS Application.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 60 MB.

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Name

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2011

If you prefer you can download and email back the application form to trust@amyac.com.au