Trust application - The Eye Lady

Irlen North Trust — Application for Funding Support

Application for Funding Support

Step 1 of 5

We're really glad you found us. This form helps us understand a little about the young person you're applying on behalf of, so we can see how we might be able to help.

It should take around 10 minutes to fill in. There are no right or wrong answers. Just do your best.

Questions marked with * are required.

About the young person

Tell us about the child or young person you are applying on behalf of.

Their first name *

Their last name *

Their date of birth *

Their gender

Male Female They prefer to describe their gender in their own words

Their school *

Their year level *

Their ethnicity (tick all that apply) *

Maori Pakeha / NZ European Pacific Peoples (e.g. Samoan, Tongan, Cook Islands Maori, Niuean, Tokelauan, Fijian) Asian (e.g. Chinese, Indian, Filipino, Korean, Japanese, Sri Lankan) Middle Eastern / Latin American / African Other European (e.g. Dutch, British, German, Australian) Something else

Are they affiliated with any iwi?

About you

Now a few details about you, as the parent or caregiver making this application.

Your full name *

Your relationship to the young person *

E.g. parent, caregiver, grandparent, guardian.

Your email address *

Your phone number *

Your home address *

Do you have a Community Services Card? *

We give priority to families who hold one, but we may still be able to consider your application if you don't.

Yes No

Please enter your card details. You will find these on the front of your card.

Card number

Expiry date

What's been happening

This helps us understand the young person's situation and what kind of support might help most.

Does the young person have any disabilities, learning differences, or neurodiversity? *

Tick all that apply.

No known diagnoses ADHD Dyslexia Dyspraxia Dyscalculia Autism Something else

What concerns have led you to seek support? (tick all that apply)

These are some of the things that Irlen Syndrome can cause.

Headaches Migraines Sensitivity to light Tiredness or fatigue Anxiety Nausea or sore tummy Trouble with reading Hard to focus at school Not wanting to go to school Something else

How much are these difficulties affecting their daily life?

0 = not at all 5 = very severely

Not at all

Severely

A few practical things

About costs

The cost of the Irlen process is different for each family. It depends on a number of things, including the provider, whether a screening has already been done (for example at school), whether the young person has previously been assessed for Irlen Syndrome, whether there has been a recent eye check, and whether any outside funding such as Enable might help with glasses or lenses.

We are not able to give you a set price before we have reviewed your application.

Which services are you seeking funding support for? *

Tick all that apply. If you are not sure, just tick what you think you might need and we can talk it through with you.

Irlen Screening TestStage 1 — checks whether Irlen Syndrome may be present Irlen Tint AssessmentStage 2 — finds the right colour filter for the young person Frames and lens costs with an optometristThe cost of glasses or lenses to hold the Irlen tint Irlen tinting costsThe cost of applying the tint to the lenses

Has the young person already been assessed for Irlen Syndrome? *

Yes No I'm not sure

If we are able to support you, is there any amount your family could contribute towards the cost?

Any contribution helps us support more families. It will not automatically exclude you, but it may help us prioritise when our funds are limited.

If funded, would you be able to travel to one of our clinics? *

Yes, we could get to Whangarei Yes, we could get to Kerikeri Yes, we could get to Albany

If none of these locations work for you, please get in touch with us before applying and we will do our best to help.

How did you hear about us? *

Through school A health professional A community organisation Your website Social media Word of mouth Something else

Is there anything else you would like us to know?

You do not have to write anything here. But if there is something important about your situation, please feel free to share it.

Just before you submit

Are you happy for us to contact you about this application? *

We may need to get in touch with a few follow-up questions to help us assess your eligibility.

Yes, please do No

Your privacy matters to us

The information you share in this form will be used by Irlen North Trust to assess whether we are able to offer funding support. It will also help us understand the difference our funding makes over time.

Your information is stored securely and only seen by authorised members of the Trust. We will not share it with anyone else without your permission, unless we are required to by law.

You can ask to see or update your information at any time by getting in touch with us.

Do you agree to your information being collected and used as described above? *

Yes, I agree No

Please check your answers above. Some required questions have not been filled in.

Sending your application... please wait.

Your answers are private and kept securely by Irlen North Trust.

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Thank you so much!

We have received your application and will be in touch soon. We really appreciate you taking the time to fill this in.

Thank you so much!

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