Equipment application form

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Child's Details

Child Demographic Information

Please tick the box that you feel is most appropriate:

Parent/Primary Carer details

Professional Details

In order to progress your application to the next stage we will require the professional support to be submitted with your application. The professional involved in your child/young person’s care will need to complete the following information in a letter on their organisation letterhead confirming:
  • Childs name
  • Date Of Birth
  • Confirmed/Suspected diagnosis or condition
  • What is the cause of the condition/disability? Prematurity? Genetic? Infection? Trauma? Cancer? Unknown? Other (Please specify in professional letter)
  • Is child/young person’s condition considered to be a: Significant disability? Life threatening condition? Life limiting condition? Terminal illness?
    • 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.
  • Why the equipment is being requested and is this considered to be urgent?
  • Full confirmation of specification.
  • Has a funding request been made to relevant statutory services/other charities, what was the outcome?

Terms and Conditions

  1. All the information given in this application process is up to date to the best of your knowledge.
  2. Newlife is a Charity and while we will try to help as many families as possible there may be occasions that we are unable to help.
  3. We will share personal information from your application with professionals working within Health/Social Care and trusted equipment providers, this helps us to facilitate the grant/loan. For more information see our privacy notice on our website.
  4. Please remember that the equipment provided should be used for the intended child/young person and should not be used by anyone else.
  5. The Equipment may be provided to you as a charitable act. We will therefore only be responsible for any loss or damage that you suffer in connection with this agreement, to the extent that we are able to claim for such loss or damage under our insurance.
  6. Following delivery of equipment, we will contact you to gather feedback on the service you received and the difference made by the use of the equipment.
If an equipment grant is offered, you are agreeing that:
  1. Newlife may offer new or fully refurbished quality equipment.
  2. Newlife will place the order directly with the equipment supplier. Please note that any orders placed with equipment suppliers prior to Newlife being able to fund will invalidate this application.
  3. Once equipment is delivered, you as the parent/carer will take on the ownership of this equipment for use of the named child/young person. If the equipment appears to have been delivered in any state of disrepair please refuse delivery and follow up with Newlife while it remains our order. Signing for the delivery means that it will be your responsibility to raise issues/concerns with the equipment supplier.
  4. The maintenance, repair and insurance of the equipment remain under your own control.
If an emergency equipment loan is offered, you are agreeing that:
  1. You won’t use the Equipment until you have received the initial training which will be provided by one of our equipment suppliers. Please follow all instructions and recommendations provided to you.
  2. 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.
  3. Please let us know if the child/young person’s needs change during the loan we may be able to support you further.
  4. We do reserve the right to recall the equipment, but we would give notice if this was the case. If the Equipment is lost, stolen or damaged whilst it is in your possession, please get in contact with us straight away and we will try to support you.
  5. 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 the 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 need to personally insure the item. You need to understand that you may also be held responsible, if you seriously misuse the Equipment or use it whilst it is knowingly faulty.

Family Declaration

It’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.

In 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.

In 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.