Supporting Professional Equipment Form (part B) Page 1 of 4Professionals FormImportant information before you proceed: Please ensure you complete this form in as much detail as possible. This will enable us to fully understand the need for the equipment. If we do not receive sufficient information, this may delay processing the application. An Emergency Equipment Loan is a free short-term loan for 6 months. This could be for a bed or a buggy to support medical needs. An Equipment Grant is a permanent provision to improve a child’s health and quality of life. This could be for a bed, buggy, wheelchair or car seat. If you need further information or wish to discuss the application process further, please contact the nurse helpline on 0800 902 0095 Monday – Friday 8am – 8pm or email the nurse helpline on Nurse@newlifecharity.co.uk Alternatively click here to view FAQ’s. First name* Surname*Job title* Profession*If your profession is not listed, please contact our nurses helpline on 0800 902 0095 to discuss the family reapplying with an alternative professional, or for signposting to other charities.Child has a postural condition - I'm an Occupational Therapist / Physiotherapist / Clinical Specialist NurseChild has a medical condition - I'm an Occupational Therapist / Physiotherapist / Clinical Specialist NurseChild has a behavioural / neurodiverse condition - I'm an Occupational Therapist / Physiotherapist / Nurse / Health Visitor / Social WorkerI confirm that I am an accredited Health/or Social care Professional and understand that, as the nominated professional, I am responsible for ensuring that the equipment and specifications meet the child's clinical needs.Accreditation numberName of organisation* Phone number*Email address*NextChild's DetailsChild's name*Child's date of birth* Child's diagnosis*Child's NHS Number*What are you supporting the request for?*Equipment GrantEquipment Loan for medical needsPlease provide the online application ID (Can be found in the subject box of the Email):*What type of equipment are you requesting?*Wheelchair (Grant only)BedBuggyCar Seat (Grant only)Equipment Code:*Please note: We only fund equipment listed in the dropdown menu below. If the item you're looking for is not listed, unfortunately, it is not something we are able to fund at this time.Please select0002 - Hannah Cot Bed0007 - Mascot Cot Bed0013 - Timmy 1 Cot Bed0025 - Delta All-Terrain Buggy0039 - Tiga Junior0040 - Tiga0041 - Octane Sub40042 - Octane FX0043 - Jane Matrix0044 - Britax Dual Fix0045 - Hernik Kidsflex - Size 10046 - Hernik Kidsflex - Size 2 (Up to 36kg) x0047 - Hernik Kidsflex - Size 3 (Up to 75kg)0048 - Hernik Ipai0049 - Hernik Starlight0053 - Stingray0055 - Cruiser0059 - Rodeo0062 - Chilla0064 - Kudu0066 - Stringray Swingout Car Seat0070 - Little Wave Clik0071 - Tough Plus Bed solid0077 - Foam Bed Base0086 - Safety Sleeper Standard Model0087 - Safety Sleeper Professional Model0089 - TinyTrax Powered Wheelchair0044 - Britax Dual Fix0090 - Imp Trike0091 - Excel Elise0092 - Special Tomato0093 - Special Tomato Jogger Buggy0094 - Ottobock Kimba Buggy0096 - Leckey WeGo0097 - ZIPPIE Voyage0098 - QUICKIE Q100 R0099 - QUICKIE Q200 R0100 - QUICKIE Q300 R Kids & Teens0101 - ZIPPIE Q300 M Mini Kids0102 - QUICKIE Q300 M Mini Pro0103 - QUICKIE Q500 M SEDEO PRO0103 - QUICKIE Q700-UP M Standing Power Wheelchair0103 - QUICKIE Q700 M HD Power Wheelchair0103 - QUICKIE Q700 M SEDEO PRO0105 - Magic Mobility Magic 3600106 - Breezy Rubix0108 - QUICKIE Argon²0109 - 0002 - QUICKIE Nitrum0110 - QUICKIE Krypton R0112 - ZIPPIE Youngster 30113 - ZIPPIE Simba0114 - Empulse R20 Wheelchair Power Assist0115 - Empulse F350116 - Empulse F550117 - Empulse StreetJet Pull Device0118 - Empulse WheelDrive Power Assist Wheels0119 - Woburn Ultra-Low Bed0120 - Carebase Lasse Cot0121 - Lisclare Junior Bed0122 - Volker Knut Cot0127 - Volker Tom Care Cot0132 - Bradshaw Junior Bed0133 - Carebase Jeremia Cot0135 - Carebase Laura Cot0136 - Axkid One 3 Car Seat0137 - Axkid One 3+ Car Seat0138 - BeSafe Beyond 360 Black Car Seat0140 - BeSafe iZi Turn B i-Size Black0141 - BeSafe iZi Twist B i-Size Black0142 - BeSafe Stretch B BlackVoyager Car SeatBeSafe Stretch Car SeatMagnetic Harness Car SeatIPAI Mini Car SeatIPAI Max Car SeatIPAI Special Needs Car SeatKidsflex Car SeatCoasterEach product in the catalogue has a unique catalogue ID, which must be entered. Failing to provide this ID will result in a delay to the child's application. For additional assistance, please contact the nurses helpline at 0800 902 0095Equipment CatalogAssessment ReportWhy is the equipment needed and what impact will this have on the child in terms of their posture?*Why is the equipment needed and what impact will this have on the child in terms of their function (activities/tasks)?*Why is the equipment needed and what impact will this have on the child in terms of their wellbeing (Inclusion/relationships/mood)?*What would be the impact to the child and family if this piece of equipment is not provided?*Has an assessment of needs been carried out by statutory services and what was the outcome?**Why are Statutory Services unable to provide the equipment?*There is lack of funding I have not made a formal funding requestI know this type of equipment will not be provided by Statutory ServicesAdvised to look for alternative funding firstDelay in child assessmentParents/Carer refused equipment offerOther If Other, please state:Is there any other relevant information you would like to share to support this application?Other ComorbiditiesWhat best reflects the current status of the child’s disability or health condition?* The child has received a formal diagnosis by a professional for the primary condition listed above.The child is undergoing investigations or is on an assessment pathway to obtain a diagnosis for the primary condition listed above.The child does not have a formal diagnosis and is not currently undergoing any investigations or assessments for the primary condition listed above.BackNextCan you please highlight the area of concern in relation to the child’s need for the requested equipment:Diagnosis/prognosis of child:*End of lifeLife-limiting/threatening condition - UNSTABLELife-limiting/threatening condition - STABLEStable conditionUndiagnosed conditionNo health/disability*Will this application for equipment prevent an immediate hospital/care admission?*YesNo* A loan to be offered if grant is selected**Discharge from hospital cannot occur without this equipment?*YesNo**A loan to be offered if grant is selectedActivities of daily living *Maximum dependency (24-hour care)High dependency (Manual handling equipment required, and needs assistance with feeding/toileting/communication)Medium dependency (Mobile, but needs assistance with feeding/toileting/communication)Low dependency (prompting/ instruction)IndependentTo what extent would this equipment support the health and safety of the child's family?*SignificantModerateLimitedNoneHow often would the piece of equipment be used?*Daily4-6 days per week2-3 days per weekOnce a weekFew times per monthOne-off event/occasionBackNextTerms 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 agreeBackSendThis field should be left blank