Equipment application form – Part A Page 1 of 6Applying for specialist disability equipment Newlife provides a range of specialist equipment up to the value of £10,000 for disabled and terminally ill children and young people across the UK. We provide wheelchairs, buggies, beds and car seats, so children and young people have the chance to fulfil their full potential. Find out more about our services.To be eligible to apply for funding, please confirm the below - all criteria must be met in order to proceed:The child is a UK residentThe child is under 19 years of age at the point of applicationThe child has a disability* that affects their daily life, which means that equipment is neededLocal services have been contacted prior to applying to Newlife to determine if they are able to meet the needs of the child (car seats excluded - please tick if applying for a car seat) Both the parent/carer and professional have read and agreed to the terms and conditions (see below)Both the parent/carer and professional have read and agreed to the privacy policy (see below)Please read our Privacy Policy and Terms & Conditions before continuing. *Newlife defines a significant disability as being a physical and/or cognitive impairment which affects activities of daily living. A life-threatening condition should be defined as a condition whereby the next period of ill health would make it likely that life-sustaining intervention would be needed. Newlife defines a life-limiting condition as a condition that results in a shortened life expectancy, as opposed to having limited life experiences that could affect quality of life. A terminal illness is generally defined as not being expected to live longer than six months and/or a person who has an advanced care plan to meet end of life care needs.NextParent/Primary Carer DetailsMrMrsMsMissOtherFirst name*Surname*Address*Postcode*Mobile Number*Other telephone numberEmail address*Have you used our services before? *YesNoHow did you hear about our services?*Word of mouthAt an eventSocial mediaSearch engine (Google)Newspaper/online articleLeaflet/brochureMedical professionalOtherWhat is your relationship to the child/young person?*Mother/adopted motherFather/adopted fatherCarer/guardianFoster parent/carerOtherDoes the parent/carer or any other children living in the household (other than the child you are applying for) have a medical condition? Please give details on any health conditions/disabilities:How will the piece of equipment applying for have an impact on the family in terms of health, social and wellbeing?*Do you receive any of the following benefits (tick any that apply)?*Universal Credit (This may include, income support, housing benefit, ESA, JSA, Working Tax Credit, Child Tax Credit)Personal Independence Payment/ Disability Living AllowanceCouncil Tax Relief Pension CreditBlue Badge Lease of vehicle through MotabilityOther means tested benefitNot applicableUnfortunately, you do not meet our eligibility criteria to apply for funding. If you wish to discuss this further, please contact our Nurses Helpline on 0800 902 0095 who may be able to help.BackNextChild's DetailsFirst Name*Surname*Date of Birth*Please enter the child's NHS number*Gender*FemaleMaleNon binaryOtherPrefer not to sayWhat is the child's ethnicity?*White - English/Scottish/Welsh/NI/BritishWhite - IrishWhite - Gypsy or Irish travellerWhite - RomaAny other white backgroundAsian/Asian UK - IndianAsian/Asian UK - PakistaniAsian/Asian UK - BangladeshiAsian/Asian UK - ChineseAny other Asian backgroundMixed ethnic background - White & Black CaribbeanMixed ethnic background - White & Black AfricanMixed ethnic background - White & AsianAny other mixed ethnic backgroundBlack/Black UK - AfricanBlack/Black UK - CaribbeanAny other Black/African/ Caribbean backgroundArabAny other ethnic groupPlease tell us the child/young person’s diagnosis and prognosis:*If undiagnosed, please upload written confirmation of this:How would you describe the child/young person’s family situation? (Tick any that apply)*Living with single parentLiving with both parentsResiding in care home/ residential/ schoolChild looked after (CLA) by the local authority Special Guardianship Order (SGO)Other (please specify) If Other, please state:What pieces of equipment is the child currently using and why?*How would the equipment you are applying for make a difference to the child's posture?*How would the equipment you are applying for make a difference to the child's function (activities and tasks)?*How would the equipment you are applying for make a difference to the child's wellbeing (Inclusion/ relationships/ mood)?*Please tell us how your child/young person is affected by not having this equipment:*Is there any other impact the piece of equipment would have on the child or family?What is the equipment you would like Newlife to consider funding? (For any equipment other than the below, please call the nurse helpline on 0800 902 0095) *WheelchairBedBuggyCar SeatDoes your child have a Wheelchair Accessible Vehicle (WAV) or one on order?*Please selectYesNoIf applying for a car seat, please state the make/model/year of the car and child's height and weight below:BackNextCan you make a partial donation towards the cost of the equipment? **YesNoWhile there is no obligation to make a contribution, if you choose to do so, the amount must be upheld in order for your application to be processedIf yes, how much can you donate?*Newlife only provides funding up to £10,000, if in excess of this can you confirm additional funding has been secured?*YesNoN/AAre there any other contributions towards the funding?PWB (personal wheelchair budget) - please upload signed agreement belowAdditional donationsOther charity fundingPlease add supporting documents:If the child/young person is currently in hospital, do they need the equipment for discharge?YesNoIf yes, please confirm the date and how long they are likely to be in hospital for.Does the child/young person have an Education, Health, and Care Plan (EHCP)?*YesNoIn ProcessIf yes, when was it last reviewed?Local services have been contacted prior to applying to Newlife to determine if they are able to meet the needs of the child (car seats excluded):*YesNoN/A - application is for a car seatIf yes, what was the outcome?If no, why?If you have chosen to contribute towards the cost of equipment but later decide to withdraw your donation, it may affect the progress of the application due to the availability of funding.BackNextProfessional Details Must be a registered professional. Before submitting your application form, please ensure you consult with your professional. Please note that once the form is submitted, Newlife cannot make any changes to the nominated professional. If you need to change the professional, a new application will be requiredFirst name*Surname*Job title* Postural/Medical specialist - Clinical Specialist/Occupational Therapist /Physiotherapist Postural/Medical specialist - Condition Specific/DMD Nurse/Nurse Behavioural/ Neurodiverse specialist - Clinical Specialist/Occupational Therapist /Physiotherapist Behavioural/ Neurodiverse specialist - Condition Specific/DMD Nurse/Nurse Behavioural/ Neurodiverse specialist - Social Worker/Health Visitor Phone number*Email address (please enter professionals email address else they will not receive the application request)*BackNextTerms and ConditionsThese are the terms and conditions of application and supply of equipment /and or accessories for Newlife Charity for Disabled Children. Application Newlife are not obliged to accept your application for any equipment and/or accessories and may, at our discretion, decline to accept your application. By submitting an application, you agree to be bound by these terms and conditions. Any services related to the provision of equipment that we provide are only provided up until the child reaches the age of 19 years. Request for funding applications are subject to eligibility. Further eligibility information can be found on our website. Funding is subject to availability. Newlife will aim to secure funds for requested equipment but cannot guarantee that these will be available. Newlife provides equipment up to the value of £10,000 only, provided as a charitable act. You must notify Newlife immediately if there are any changes to your contact details, address or other circumstances during the application process. SUPPLY OF EQUIPMENT (Grants) Newlife may offer new or fully refurbished quality equipment. Newlife will place the order directly with the equipment supplier on your behalf. Any orders placed by anyone other than Newlife prior to funding being approved will result in the application becoming invalid, and you may be liable for the costs incurred Once the equipment is delivered its ownership becomes that of the Child's parent/carer. Should a defect in the equipment delivered be identified you must notify the supplier/professional immediately. It is your responsibility to check the equipment is in good and safe working order and should check this each time before use. Equipment provided must be used in accordance with the instructions, demonstration and guidance given by the supplier. You must only use the equipment and/or Accessories for the child it was issued to for the purpose that they are designed and in the manner that professional and the relevant supplier instructs. The maintenance, repair and insurance of the equipment is the sole responsibility of the child's parent/carer. You must ensure that all equipment and/or accessories continue to be suitable for use. If the equipment is no longer suitable (for example, the child experiences any discomfort or if you suspect that the child has outgrown the Equipment) or the Child’s functional needs have changed, you must get in touch with your professional. At your own cost you should seek to insure equipment with an insurance company of good repute under a recognised specialist policy. The policy must include, without limitation, insurance against damage or loss to any third party. Newlife reserves the right to refuse any future applications if you are in breach of its terms and conditions. SUPPLY OF EQUIPMENT (Loans) Newlife may offer new or fully refurbished quality equipment. Equipment within our loans suite is subject to availability. Equipment loans are provided for up to 6 months. We only consider extensions to this period in exceptional circumstances and cannot guarantee. Equipment provided must be used in accordance with the instructions, demonstration and guidance given by the supplier/professional, and equipment should not be used until this has been completed. If you no longer need the equipment, please contact us and we will arrange for the equipment to be collected from your home or nominated address. It is the responsibility of the parent/carer to inform of us on 0800 902 0095 of any changes to the child/young person’s needs during the loan period. Newlife reserve the right to recall loaned equipment. Wherever possible adequate notice will be given. If the Equipment is lost, stolen or damaged whilst it is in your possession, you should call Newlife immediately to report. Ensure that the equipment and/or accessories are always stored in a safe place when not in use. Newlife will insure against all loss, theft or damage to the Equipment; public liability; and product liability whilst you are in possession of the Equipment. Our insurance covers: Equipment whilst it is in the United Kingdom and for up to 90 days in other countries of the European Union. For use outside of these conditions, you will need to contact us to get approval. Under these circumstances, you may be liable to insure the equipment. The equipment remains under the ownership of Newlife throughout the loan period. You must not dispose of, or pass the equipment onto another person; you must let us know immediately if you have no further use for it. You must not alter or tamper with the equipment and/or accessories in any way without professional and/or the relevant suppliers prior approval. You may be responsible for the damage, if you seriously misuse the loaned equipment or use it whilst it is knowingly faulty. GDPR We need to collect data about you, your child, and your family to process your application. Our Data Protection Policy explains what data we will collect, how it will be used, how long we keep it for, and what you need to do if you wish to see what data we hold about you. By submitting an application, you are acknowledging the contents of this statement. Please read this statement carefully and contact us if you have any questions. I agree to the terms & conditions*I agreeFamily declaration Newlife replies on donations to provide essential specialist equipment to families, any information we can share with our donors helps us to fund our services and help more families in need. Please consider sharing your story with us once you've received your piece of equipment to encourage more support and reach even more families across the UK.Do you agree to Newlife providing the child/young person’s basic information to help demonstrate how specialist equipment can change young lives, help promote our services to other families, encourage fundraising and donations as well as help raise general awareness of the charity?*YesNoIt’s important, that we can share some basic information. This is common with most charities who are highly dependent on the public to help them meet the needs of children and their families.Would you be interested in speaking to our volunteering team about wider opportunities to support the charity? *YesNoDo you consent to allow Newlife to share your personal data with third parties to help Newlife analyse what we do? *YesNoIn these cases Newlife will remain the Data Controller but will simply share your data for the purpose of data analysis only. In all cases we will use a non-disclosure agreement to ensure that the third party does not misuse any data provided.As a charity, it is necessary to raise funds to be able to continue our service to children and families. Are you happy to receive updates and news including other ways to get involved from our fundraising team? *YesNoIn these cases Newlife will remain the Data Controller but will simply share your data for the purpose of data analysis only. In all cases we will use a non-disclosure agreement to ensure that the third party does not misuse any data provided.For all the questions above where we ask you if you are happy to be contacted by a Newlife team, other than the Child and Family Support Team, please specify your preferred method of contact (please tick all that apply):By PostBy emailBy phoneBackSendThis field should be left blank