Wishing Well Application Form

Parent / Guardian / Representative Details

Child Details

Has your child ever accessed KidzWish programs? (Currently or in the past)

Application Request

You may be required to provide quotes and supporting documents for your application. If you have any therapist reports to assist your application, please prepare.

Our team will be in contact with you via phone or email if this is required.

  • If your application is approved, KidzWish may wish to publicise its work, in conjunction with your appeal, to both electronic and print media. I give consent to KidzWish to use my/our photos in their own publications and on social and digital media in conjunction with the promotion of the application and the Wishing Well program.
  • I give my consent for KidzWish to generate publicity should my/our appeal be successful.
  • All reusable items remain the property of KidzWish. We undertake items to ensure any reusable items are returned in good order to KidzWish for reallocation through the Wishing Well Application when no longer required.
  • Privacy collection statement. Your privacy is respected by KidzWish. The personal information you provide on this form will be used to assess your eligibility or for the administration for our Wishing Well Program. It may be provided to organisations that will assist us in the process, or as required or authorised by law, but we will not use any of your sensitive information for marketing purposes, without prior written consent. If you have any privacy concerns please contact us to make arrangements.
  • I consent to KidzWish collecting the information provided on this form. I understand that if I do not provide the information requested, I may be ineligible to receive assistance from KidzWish.
  • I confirm I have read and understood the program details, process and selection criteria for the Wishing Well Program.

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