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Musical Moments Trust Scholarship Form
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GENERAL INFORMATION
What is the Musical Moments Trust?
The Musical Moments Trust was established as a result of an inspirational boy who regardless of his situation and what was happening around him, smiled, danced, played instruments, sang to music and created songs. Music was a moment away from reality.
The Musical Moments Trust scholarship is offered to pre-school and primary school aged children living with cancer, to fund positive musical experiences for they as they move through their treatment and beyond. Past recipients have enjoyed private and group music lessons, home visits from a music therapist, musical instruments and the chance to create and record a song with a musician.
Who can apply?
To apply for the Musical Moments Trust your child must be:
- A Challenge member who has been diagnosed with cancer or a life threatening blood disorder
- Aged between 0 and 12 years inclusive
As a parent or carer, you may apply each round until your child is 13 years old.
CONFIDENTIALITY
All information contained within this application will remain strictly confidential.
CHALLENGE SCHOLARSHIP
In order to be considered for this scholarship, applicants are required to have completed a Challenge Membership Form. If you have not completed a membership form, please contact the Challenge office on (03) 9329 8474.
Declaration
I, the parent/guardian of the child in which this application form is for, hereby endorse and support this application and confirm that all the information provided in this document is true and accurate at the time of signing.
Signature
Should your child receive funding from the Musical Moments Trust, would you as a parent/guardian allow a photo and caption to be placed on Challenge social media pages?
Yes
No
Should your application not be successful in this round of funding, would you like it to be resubmitted for the next round of funding?
Yes
No
Personal Information
Applicant Name
First
Last
Date of Birth
Date Format: DD slash MM slash YYYY
Gender
Male
Female
Primary Address
Street Address
Address Line 2
Suburb
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Contact Email
How have you found music to benefit your child during hospital treatment or at home?
How do you think the Musical Moments Trust will help develop your child's language skills or physical development?
Should your child receive funding from the Musical Moments Trust, what would the funding go towards?
Medical Information
Diagnosis
Date of Diagnosis
Date Format: MM slash DD slash YYYY
Hospital
Doctor
Has the patient suffered a relapse?
Yes
No
Other medical information:
How has the treatment affected your child physically?
Other comments:
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