Online Wellness Grant Application

Full Name*

Address*

Contact Number*

Email Address*

Age*

Diagnosis*

Are you currently receiving any medical treatment?*

Yes
No

Please provide brief details*

When did you you last receive treatment?*

What type of wellness program would you like to be funded to attend or participate in? (Please provide as much detail as possible)

How would this program support your recovery?

What is the estimated cost of attending the wellbeing/spiritual program or activity?

Program/activity costs

Travel costs

Other costs

Contributions from other sources

Total grant amount requested (up to a maximum of $500)

Are you currently working or receiving any other type of income (e.g. Centrelink payments)?

Have you previously applied for or received a grant from The Christina Ghobadi Foundation?

Yes
No

Please provide details.*

Where did you hear about the organisation?*

For help with completing this form, please contact The Christina Ghobadi Foundation on (03) 9437 9403 or by email info @ cgfoundation.org.au

Grant applicants will be advised of the outcome of their application within four weeks from receipt of the application.

All information provided will only be used for the purpose of accessing eligibility for a grant from The Christina Ghobadi Foundation. For more information please see our privacy policy on our website.

What is the estimated cost of attending the wellbeing/spiritual program or activity?

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