Past Player Health and Wellbeing Grant Form 2019-20

ACA PAST PLAYER PROGRAM

Past Player Health and Wellbeing Grant Application 2019-20
Name*

First NameLast Name
E-mail*
Best contact email address
Phone Number*
Please remember to include an area code if you are providing a landline number
Please select yes box to continue to submit your grant in 2019-20?*
Government Issued Pension Card or Health Care Card holders are eligible for $500 all other Members are eligible for $200
Do you have any of the following Cards*

NoPensioner Concession CardHealth Care CardOther
Customer Reference Number (CRN)*
If you have a government issued card please enter the Customer Reference Number(CRN)
Please Submit Proof of Payment

The ACA require proof of payment documents before we can reimburse you. You must have incurred these expenses between July 1st 2019 and June 30th 2020
Eligible Services include:

HEALTH

Health Insurance Premiums

MEDICAL EXPENSES

Massage, Physio, Chiro, Optical, Medications etc

FITNESS

Gym/Sport Club Membership, Fitness Equipment (Runners, Treadmills, Exercise Bikes etc)

CAREER and EDUCATION

Education, Training, Seminars, Conferences, Career Coaching

LIFE and FINANCE

Income Protection, Business Insurance, Will Preparation, Prepaid Funeral, Financial Health Check/Advice OR any other expenses
Chosen Service*
Please select the service you are claiming a reimbursement for.
Amount you have paid*
Please enter the amount shown on your Receipt or Bank Statement.
Please check your receipts are dated in the 2019/20 Financial Year before continuing.*

Yes the receipts are in the 2019/2020 Financial year
Proof of payment*

Upload a File
Please provide proof of payment such as a Receipt or Bank Statement. Clear photo/screen shot of these document are OK. You can upload multiple files if required. Cancelof
Reimbursement details

Please provide account information that you wish the reimbursement to be deposited
Name of Bank or Financial Institution:*
Insert bank name
Account Name: *
Insert account name
Account BSB: *
Insert account BSB number
Account Number: *
Insert account number
How will this grant assist you in life after cricket?
Are you happy to share the above feedback with ACA members*

YesNo
Thank you for taking the time to complete this Form.

If you have any questions please do not hesitate to contact the ACA Past Player Team on 03 9698 7207 or acagrants@auscricket.com.au
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ACA PAST PLAYER PROGRAM

Government Issued Pension Card or Health Care Card holders are eligible for $500 all other Members are eligible for $200

Please Submit Proof of Payment

Reimbursement details