AnglicareCQ Emergency Relief Application Form

PRIVACY NOTICE: Anglicare Central Queensland is collecting the personal information you supply on this form for the purpose of providing Emergency Relief. Your personal details will not be disclosed to any other person or agency external to Anglicare Central Queensland without your consent unless required or authorised by law.

About Emergency Relief

Purpose: To assist the people of Central Queensland in the emergency relief of financial hardship.

Applications should only be submitted once all other reasonable options have been exhausted. Applications are assessed on a case-by-case basis. The applicant must provide as much documentation as possible to support their application. Financial support is provided:

A maximum of once per quarter
Per household not per individual

Please note that Anglicare Central Queensland's Emergency Relief program operates with limited funding. As a result, assistance is subject to the availability of funds and resources at the time of assessment. Meeting the eligibility criteria does not guarantee support.

Supporting Documentation

In order to process your application you must provide supporting documentation. Documentation should be uploaded with this form.

Supporting documentation includes:

Copy of full and current Centrelink Income Statement or Pay slip for all household members receiving an income
Copy of outstanding or overdue bills /rent
Copy of receipt for payment of bill or recent expense

Your application cannot be submitted without documentation

Location

Which of the following AnglicareCQ offices is your local office? *

Rockhampton/YeppoonBiloela/MouraBarcaldineOther

Unfortunately, you reside outside our service areas and are not eligible for assistance.

You may be able to access Emergency Relief from another provider.

Search Ask Izzy for more details.

Applicant's personal details

First name *

Last name *

Phone number *

Date of Birth *

Email *

Current Address *

Street address *

City *

Postcode *

Country of Birth *

AustraliaOther

Country of birth (if other than Australia):

Main language spoken at home *

EnglishOther

Main language spoken at home (if other than English):

Indigneous Status *

AboriginalTorres Strait IslanderAboriginal & Torres Strait IslanderNon Indigenous

Health details

Do you have a health condition or disability? *

YesNo

If yes, which category best describes your health condition or disability??

Intellectual / LearningPsychiatricSensory / SpeechPhysical / Diverse

Income and household details

What is your main income source? *

Centrelink BenefitSalary / WagesOther

If you chose 'Salary / Wages' on what basis are you employed?

Full timePart timeCasual

How many adults in your current household? *

How many children (under 18 years old) in your current household? *

AnglicareCQ support details

Are you being supported on an ongoing basis by a team member at AnglicareCQ? *

YesNo

E.g. a Tenancy Management Officer, Homelessness Case Manager, or Support Facilitator

If 'Yes' please provide their name and program:Please note by providing your support worker’s name, you consent to us contacting them regarding your application where required.

Reason for seeking assistance

What are you seeking Emergency Relief for? *

FoodOther

Other reason for seeking Emergency Relief

What has happened recently that has caused you to apply for financial assistance? Please provide as much detail as possible to support your application. *

Consent

I hereby acknowledge Anglicare Central Queensland has advised me of the following (please tick) :

Anglicare Central Queensland’s Confidentiality and Privacy Policy *

That my data may be stored in Australian or overseas cloud based systems. *

Circumstances that may require the disclosure of my personal information. *

My right to access my personal information. *

My right to request to have any incorrect, incomplete or misleading personal information reviewed *

My right to have my information and views as a participant accurately reflected within my file *

My right to withdraw my consent at any time *

My right to approach the Human Rights Commission if I feel my rights have been violated. *

I am aware of and understand that Anglicare Central Queensland may need to collect and disclose personal information to third parties but will only do so as required by law and/or with my consent so I may receive services. I understand that Anglicare Central Queensland must comply with relevant privacy laws and I will contact the orgnaisation immediately if I feel that these laws have been breached. I nominate that my personal information can also be disclosed to the person/s or providers listed below: *

Australian Government Dept of Social Services

Documentation

To process your application, you must provide supporting documentation.

If submitting online, please upload your documentation below. If submitting a paper application, ensure all supporting documentation is attached to this form.

Supporting documentation includes:

Copy of full and current Centrelink Income Statement or Pay slip for all household members receiving an income
Copy of outstanding or overdue bills /rent
Copy of receipt for payment of bill or recent expense

Please note you cannot submit an application without documentation!

Upload Documentation *

Browse

Please upload your documentation here

Authorisation

By applying for this support, I agree to provide Anglicare Central Queensland with consent to collect and disclose my personal information, and understand that by withholding or withdrawing this consent that Anglicare Central Queensland may not be able to start or continue services.

I declare that I have provided the required documentation (listed above), and that the information provided in this application is true and correct.

Signature *

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