Child Drowning Support Fund Application

Name of child impacted by non-fatal drowning incident *

Child's date of birth *

Name of applicant *

Postal address *

Suburb *

State *

Post Code *

Phone number *

Email Address

Please tell us about your child's drowning incident. *

Please provide a brief description of the medical/hospital care received at the time of their drowning and subsequent medical care that has been required. *

Please describe the resource, services or support requested. *

Approximate value of the resource, services or support requested. *

(an exact figure is not required, we will finalise this with you during the application process)

How will this funding make a difference for your child and family? *

Comments

I have existing quotes or documentation from suppliers, or receipts of items already paid for which I can provide.

YesNo

I agree that I have not received funding for the requested resource, service or support from another organisation or entity

I agree to provide Royal Life Saving WA with written quotes and/or tax receipts for the requested items as required *