Complete the referral form!

Important information:

This form is designed to be filled in by Healthcare Professionals only.
Applications for grants can only be made for children who have been admitted in hospital for 6 weeks (42 days) or more.
You cannot apply for the same grant more than once in a 12 month period, but are able to apply for different grants. (Eg. You cannot apply for two 'Going Home Wishes' within 1 year, but you could apply for a 'Going Home Wish' and a 'Comfort Fund' in that 1 year period.)

When filling out the form, please ensure you have all the correct information. If you require any information or assistance when completing this form, please Contact us.

Refferer's Details

First Name

Last name

Profession

Your phone number

Email

Child's & Parents details

Childs First Name

Childs Last Name

Child's DOB

Date

Name(s) of Parent/guardian

Parent/guardian phone number

Parent/guardian Email address

Child's Address

Address 1

Address 2

City

County

ZIP / Postal Code

Admission Details

Date of Admission

Date

Current length of stay (days)

Admission must be over 42 days to be eligible for grants from the Harley Jae Trust.

Reason for admission

750 words left

Referrers Declaration

I confirm that the information provided in this referral is, to the best of my knowledge, accurate and complete. I understand that any false or misleading information may impact the outcome of this referral. I have obtained appropriate consent to share this information with The Harley Jae Trust.

Referrer's Signature

Referrer's Name

Referrer's Confirmation Date

Date

Refer a child to The Harley Jae Trust!

Complete the referral form!

Important information:

Refferer's Details

Child's & Parents details

Admission Details

Grant details

Referrers Declaration

Donate to The Harley Jae Trust today!