Subsidy Claim Form

Each calendar year Cystic Fibrosis Queensland offers reimbursement of expenses for medication support, physical activities and parking. We may also be successful in applications for grant monies to help fund cleaning, events, or home-use respiratory equipment.

• Applicants must be a current Queensland member of Cystic Fibrosis Queensland and have a diagnosis of cystic fibrosis.

• A complete application form must be provided along with evidence of the expense being claimed.

Contact services@cfqld.org.au to find out if other subsidies are available.

Member Details
Your name

Your email

Street address

Suburb

State

Postcode

Phone

Date of Birth

I am currently a member of Cystic Fibrosis QueenslandIf no/unsure I give Cystic Fibrosis Queensland permission to deduct the membership fee from my claim

Child's Details
Your child's name

Your child's Date of Birth
Child's gender

Claim details

For PAS, Parking and Medical Expense claims, submit the receipt as proof of purchase. For Parking claims the specific location must be evident on the receipt.

Physical activity subsidy

Items purchased

Total of claim - (max-$150)

Parking and Medical expense subsidy

Items purchased

Total of claim - (max-$200)

Reimbusement details
Bank

BSB

Account number

Account name

Supporting evidence
Allowable file formats: (.doc/.docx/.pdf/.jpg/.jpeg/.png)

Any additional information

I declare that all information I have provided to Cystic Fibrosis Queensland is true and accurate. I understand if it is found that I have knowingly provided false or inaccurate information I may no longer be eligible to be a member or receive future services and benefits provided by Cystic Fibrosis Queensland.

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