Before we begin
Complete this form if you are requesting services as the parent or guardian of a child. You will be the primary contact person for this enquiry.
Fields marked with
*
are mandatory
Is the child currently receiving services from Vision Australia?
Yes, they are an existing client
No, or I'm unsure
Do you have permission to submit the form for the child?
Yes I am the parent or guardian of the child
Only a parent or guardian can request services for a child. Providing your information confirms your agreement to discuss services and share personal information with Vision Australia. We handle information in accordance with our
privacy policy
.
Your details
Step 1 of 4
Step 1 of 2
Fields marked with
*
are mandatory
What is your relationship to the child?
Please select...
I am a parent to this child
I am a step parent to this child
I am a foster parent to this child
I am a grandparent to this child
I am the child’s legal guardian
Other relationship
Your first name
Maximum 32 characters
Your last name
Maximum 32 characters
Your phone
Enter 10 digits without spaces starting with ‘0’ for mobile or phone with area code.
Your email
If you do not have an email address, enter the email of a family member or carer, or call us on 1300 84 74 66.
Contact preferences
Do you require an interpreter?
Yes, for languages other than English
No, I do not require an interpreter
Select your preferred language
About the child
Step 2 of 2
Step 2 of 4
Fields marked with
*
are mandatory
Please fill in the following information for the child for which you are the parent or guardian.
Their details
Child's first name
Maximum 32 characters
Child's last name
Maximum 32 characters
Child's date of birth (DD/MM/YYYY)
Child's postcode
Maximum 4 characters
Is the child of Aboriginal and/or Torres Strait Islander origin?
Please select...
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander
Unsure
Prefer not to say
We ask this question to provide culturally appropriate, prioritised access to programs and services, and to improve overall health outcomes.
Their needs
What has prompted you to seek services on their behalf?
Please select...
They are newly diagnosed with a visual condition
They have deteriorating vision
A change in life situation where they need extra support
Seeking equipment to enhance their remaining vision
Other
Is there anything you would like to tell us about the child or this service request?
By submitting this form, you confirm that you agree to the storing and processing of your personal data by Vision Australia as described in our
Privacy Policy
. The information you have submitted will be used to provide you with the most relevant content on Vision Australia services, news & events, and other opportunities for support
Their vision
Step 3 of 4
Fields marked with
*
are mandatory
What is the child's primary eye condition?
I don’t know their eye condition
Albinism
Cerebral Vision Impairment (CVI)
Congenital Cataract
Glaucoma
Nystagmus
Optic Nerve Hypoplasia
Retinopathy of Prematurity
Retinitis Pigmentosa
Other eye condition
Enter their eye condition
What has prompted you to seek services on their behalf?
Please select...
They are newly diagnosed with a visual condition
They have deteriorating vision
A change in life situation where they need extra support
Seeking equipment to enhance their remaining vision
Other
Funding status
Step 4 of 4
Fields marked with
*
are mandatory
If the child is eligible for a funding source or government support (such as NDIS) you need to access it to receive services from us. Alternatively, you can choose to speak to us about other options to access services.
Is the child connected to a funding source or government support?
Yes, they have funding
No, they do not have funding
I'm not sure
Which organisation provides the majority of their funding?
NDIS (National Disability Insurance Scheme)
I’m not sure who provides their funding
Other
Enter details on who provides their funding
Their needs
Is there anything you would like to tell us about the child or this service request?
By submitting this form, you confirm that you agree to the storing and processing of your personal data by Vision Australia as described in our
Privacy Policy
. The information you have submitted will be used to provide you with the most relevant content on Vision Australia services, news & events, and other opportunities for support