Application For Housing Assistance Form Page 9
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19Name of the person(s) with the disability or medical condition
Disability or medical condition
Kidney failure
Family Name
First Name
Wheelchair user
Family Name
First Name
Physical disability
Family Name
First Name
Hearing impairment
Family Name
First Name
Physical illness
Family Name
First Name
Chronic/terminal illness
Family Name
First Name
HIV/AIDS
Family Name
First Name
Mobility impairment
Family Name
First Name
Experience of torture and trauma
Family Name
First Name
Other
Medical condition
Family Name
First Name
28. Do you or anyone on this application
Yes
No
Go to 29.
require access to a specific service
give details
or school because of a medical
condition or disability?
Name of person
Attach documents that
Family Name
First Name
requiring access
support your answer.
to the school
See item 17 on the
Evidence Requirements
or service
Information Sheet
Which school/
for details.
service?
For what reason?
For how long will it be required?
29. Do you or anyone on this
Yes
No
Go to 30.
application receive ongoing support
give details
from an organisation, program
or a person?
(for example, from NDIS, HASI, a carer, etc.)
Note: If you have already provided these details
in response to question 8b you do not need to
repeat them here.
Attach proof, or give your consent for
information to be exchanged with your support
provider. See item 18 on the Evidence
Requirements Information Sheet for details.
Name of person
Family Name
First Name
receiving support
Name of organisation or program
providing support (if relevant)
Name of support worker or person
Family Name
First Name
Contact phone number
Email
DH3001 04/15
Page 7 of 16
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