Musical Moments Trust Scholarship Form

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
- Have not previously been awarded the Musical Moments Trust Scholarship
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? Please note, applications can only be resubmitted once.
- Yes
- No

Personal Information
Applicant Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Gender
Primary Address*
Street Address Address Line 2 Suburb State / Province / Region ZIP / Postal Code Country
Contact Email
Does your family primarily speak a language other than English in the home? If yes, what language do you speak?

How have you found music to benefit your child during hospital treatment or at home? (50-100 words)*
Did your child access music therapy while in hospital?*
- Yes
- No
If yes, how often?
What are you hoping the Musical Moments Trust Scholarships will help your child with? You can select more than one option.*
If other, please specify:
Should your child receive funding from the Musical Moments Trust, what would the funding go towards? Please be specific.*

Medical Information
Diagnosis*
Date of Diagnosis
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 and mentally? (20-100 words)*
Other comments:

Musical Moments Trust Scholarship Form

Declaration

Personal Information

Medical Information