Victoria Application form If this form is downloaded from the web please print all pages and complete by hand. How to apply 1. The applicant is the person with the disability. All items from Item 1 to 8 and Item 11 must be completed. 2. Obtain two current, high quality, colour passport sized photos (4.5cm x 3.5cm), and attach to this application. The photographs need to be of the head and shoulders only. The photographs need to be signed by the health professional or service provider who completes Item 9 and Item 10 confirming the photograph is of the applicant. 3. If the applicant is unable to complete or sign the form, the applicant’s legal guardian or agent may complete or sign on the applicant’s behalf. 4. Return this application to: Companion Card Applications G.P.O BOX 4987, Melbourne VIC 3001 Please note: • Incomplete applications, including those without signatures or signed photographs, cannot be processed. • An application takes up to 30 working days to process and can take longer if incomplete information is provided and further information is requested. Please check before sending: Has the form been signed by the service provider or health professional that completed Item 9 or Item 10? Have the photographs been signed by the same service provider or health professional who completed Item 9 or Item 10? Have copies of any assessments or reports been included? Has the applicant or legal guardians/agent signed the form on page 13? 1 1709008_Companion Card Application form 16pp.indd 1 16/11/17 10:56 am About the Companion Card The Victorian Companion Card was developed to promote the rights of people with a disability to fair ticketing. Companion Card is for people with a significant permanent disability, who always need a companion to provide attendant care type support in order to participate at most available community venues and activities. Please go to page 15 and 16 for more information. Eligibility criteria To receive a Victorian Companion Card, the person must: 1. be a permanent resident of Australia and residing in Victoria 2. demonstrate that they have a significant, permanent disability 3. demonstrate that, due to the impact of the disability, they would be unable to participate at most community activities without attendant care support 4. demonstrate that the need for this level of attendant care will be lifelong. Attendant care support includes significant assistance with mobility, communication, self-care or learning, where the use of aids, equipment or alternative strategies does not enable the person to carry out these tasks. The Companion Card will not be issued for conditions with infrequent or unexpected events such as allergic reactions, falls or medical emergencies. The Companion Card is not issued to every person who has a disability. The card is issued to people who can demonstrate that they would not be able to participate at most venues and activities without attendant care, and that this need can be demonstrated to be lifelong. People on NDIS Plan are not automatically eligible for a Companion Card. Each application will be assessed against the Companion Card eligibility criteria. Companion Cards cannot be issued if the applicant may become independent in the future as a result of treatment/management, training, recovery or developmental improvements. Getting more information about the Companion Card Website: www.companioncard.org.au Email: companioncard@dhhs.vic.gov.au Information line: 1800 650 611 between 9.00am and 4.00pm National Relay Service: 13 36 77 Speech-to-sppch Relay Service: 1300 555 727 Interpreting services: 131 450 2 1709008_Companion Card Application form 16pp.indd 2 16/11/17 10:56 am Please complete this application form in BLOCK LETTERS using blue or black pen and tick the tick-boxes. Note: Replacement cards are not issued using this form. To replace a lost, stolen or damaged card, call 1800 650 611 or download the ‘Replacement/change of details form’ on www.companioncard.org.au Applicant information Item 1. This application is a: (please tick one) New Companion Card application If the applicant has never received a Companion Card. Renewal of an existing or expired Companion Card Card number if known: 3 1709008_Companion Card Application form 16pp.indd 3 16/11/17 10:56 am Item 2. The Companion Card will only be issued in the name of the person with the disability. One application must be completed per applicant. Applicant’s title: (e.g. Mr/Mrs/Ms/Miss) Surname: Applicant’s first name as it appears on official documentation such as a Birth Certificate: Applicant’s preferred name to appear on the Companion Card: d d / Date of birth: OR If date of birth unknown, approximate age in years: Male Gender: Telephone: / ( m m / y y y y / Female Prefer not to respond Self describe ) Mobile: Email (if available): Residential address: Suburb: Postcode: State: Postal address (if different from above): Suburb: Postcode: State: 4 1709008_Companion Card Application form 16pp.indd 4 16/11/17 10:56 am Item 3. Please tick the boxes that best describe the applicants disability. (More than one box may be indicated with a tick.) Physical (e.g, Muscular dystrophy, quadriplegia cerebral palsy) Sensory (e.g, Legally blind, deafblind) Intellectual (e.g, Down syndrome, Fragile X syndrome) Neurological (e.g, Alzheimer’s disease, Huntington’s disease) Acquired brain injury (e.g, Stroke) Psychiatric (e.g, Schizophrenia) Please attach reports. Item 4. What is the applicant’s specific diagnosis or condition? Please use the space below to briefly describe the condition. Item 5. Is the applicant’s need for attendant care support to access community venues and activities permanent (lifelong)? Yes, the applicant has a lifelong need for attendant care to access most community activities and events. Proceed to Item 6 Conditions that are episodic or cannot demonstrate a lifelong need for attendant care assistance to access activities and events cannot be issued with a Companion Card. No, please do not proceed with the application. 5 1709008_Companion Card Application form 16pp.indd 5 16/11/17 10:56 am Item 6. Using the boxes below, describe the applicant’s need for lifelong attendant care in the areas of mobility, communication, self-care and learning planning and thinking when accessing a community event or venue. • Include examples of the attendant care the companion provides. • If the applicant’s condition is episodic, describe the frequency of the episodes. • Provide the date and location of diagnosis. • Describe the applicant’s use of aids or equipment. • How does the applicant currently access community venues and activities? • Point form is acceptable. Assistance required guide for completing form Minimal – can perform 75% or more of task Some – can perform 50% to 74% of task Substantial – can perform less than 50% of tasks Mobility Minimal Some Substantial assistance required Some Substantial assistance required Communication Minimal 6 1709008_Companion Card Application form 16pp.indd 6 16/11/17 10:56 am