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Newlife the Charity for Disabled Children - Registered Charity Number: 1170125 in England & Wales

Emergency Equipment Loan Application Form of 16

Emergency Equipment LoansNewlife runs the UK’s only Emergency Equipment Loan service, providing equipment free of charge to children who are in very urgent need. This emergency service is for those children who cannot wait for equipment, because there is a significant risk of injury, the child has a shortened life expectancy and/or complex unstable conditions. We can also provide an emergency equipment loan so a child can be discharged from hospital and hospice. Newlife aims to deliver all emergency equipment loans within 72 hours. The initial loan term for the emergency equipment is six months and is often to address a short term, urgent need. Note, the loan period can be extended subject to approval by Newlife.

We will assess the urgency of the need by considering the impact on the child/young person’s health, safety and quality of life. If we award an emergency equipment loan, we will place the order and aim to deliver the equipment within 72 hours. Training on how to use the equipment (if necessary) is carried out by the supplier or supporting local professional.

You can apply for equipment through any of our grant and loan services as often as the child/young person requires essential equipment to meet their specialist needs.

To be retained for your reference purposes.

Emergency Equipment

The suite of equipment includes beds/cots, wheelchairs and buggies, seating and hoists. The availability and type of equipment will vary day to day as equipment is returned and new items added. All equipment is clinically cleaned, refurbished, technically tested and maintained by professional equipment specialists and suppliers prior to each loan. To view the equipment available through this service and availability, please visit www.newlifecharity.co.uk/eel

Lilly’s Story

“For three-year-old Lilly night-time is a nightmare. She repeatedly bangs her head against the side of her cot bed, gets her arms and legs stuck, leaving her bruised and at serious risk of injury. Lilly has severe developmental delay and no awareness of danger. Her mum Marie barely sleeps, staying awake to make sure Lilly doesn’t hurt herself. Although she’s applied to local health services for a specialist padded bed, it will take months to process. In desperation she turned to Newlife who recognised the severity and urgency of the family’s situation and delivered a specialist bed for Lilly within 24 hours through its Emergency Equipment Loan service. Marie said: “The loan bed has made a massive difference to our lives, night time is much more peaceful now!”

What You Can Expect

Newlife covers all costs towards the loan of this equipment, including;

Installation and adaptations Training Maintenance Insurance

Additionally once the equipment has been received, we will proactively work with local health and social care professional to ensure child-centred collaboration so those with a statutory and legal responsibility to fund appropriate equipment provide a longer term solution.

Upon receipt of your application, we will inform you if the piece of equipment you require is still available (and if not explore alternative options). Newlife will also contact your named supporting professional to ensure that the equipment is appropriate to meet the child/young person’s needs. Once we have enough information to progress with provision we will confirm that the costs have been authorised and arrange delivery at a mutually agreed time - usually within 72 hours of receiving information from your professional.



Emergency Equipment Loan Application FormManaging Your InformationIf you would like to know more about what we do, or help us in other ways that could help change the lives of disabled children and their families then please tick the boxes below. The permissions associated within this section refer to the applicant’s details rather than anyone else referred to in the application.

Do you agree to receive additional information about Newlife’s Care Services? Yes No

If ‘Yes’, we will contact you initially to provide details about all of our Care Services and then as we develop and update each individual service.

Do you agree to Newlife providing the child/young person’s name, age, residential county and description of their condition and reason for why you need the equipment to donors and supporters to demonstrate how equipment can change young lives demand for services and encourage financial donations?

Yes No

If ‘Yes’, we will share this information because we know that our supporters are inspired to help again when we tell them about the children we have helped. So it’s important, that we can share some basic information. This is common with most charities who are highly dependent on the public to help them meet the needs of children and their families.

Do you agree to provide a photo of the child/young person that could be used to highlight their specific need for the equipment within this application?

Yes No

If ‘Yes’, please note that this can be sent by email to [email protected] or by Royal Mail standard delivery.

If a loan is provided as part of this application, and following subsequent delivery of the equipment, do you agree to Newlife contacting you to gather feedback on the service received and difference made by this short-term urgent loan?

Yes No

If ‘Yes’, Newlife will email or telephone you three months after equipment has been provided.

If a loan is provided as part of this application, and following subsequent delivery of the equipment, do you agree to speak to our media team about the difference the equipment has made in order to raise awareness of our services to other families in need?

Yes No

If ‘Yes’, our media team will contact you once the equipment has been delivered to find out how it has helped the child/young person and if appropriate, your family as a whole. If you wish to help us develop a media story for awareness or fundraising purposes, the media team will seek additional permissions.

Would you be interested in speaking to our fundraising and volunteering teams about wider opportunities to support the charity?

Yes No

If ‘Yes’, as fundraising and volunteering opportunities arise, we will contact you to see if you would like to offer support; on average this would not be more than five times a year.



Do you consent to the data provided in this application to be anonymised (removal of all personal data) and analysed for the purpose of research and reporting on the work of the charity?

Yes No

For all the questions above where we ask you if you are happy to be contacted by a Newlife department other than Care Services, please specify your preferred method of contact:

By post By email By phone

Name

Signature Date

We, Newlife the Charity for Disabled Children, are the ‘Controllers’ of the personal data and health information we collect. We need to collect and process certain information to allow us to provide any of the named Care Services below. To see Newlife’s full privacy notice, please visit http://newlifecharity.co.uk/docs/general/Resources-and-Documents.shtml



As the applicant, please state if you are the: Parent/Main Carer Child/Young Person

If the child/young person is to be contacted directly regarding this application, please still complete the section below to provide parent/carer details so that they can be informed and involved in future communications.

If the recipient Child/Young Person is not the applicant, what is the relationship of the applicant to the child/young person?

Emergency Equipment Loan Application FormWho Is Completing This Form?This form should be completed by someone with parental responsibility and/or the main carer of the child/young person who needs equipment. However, if a child/young person aged 12 or over wishes to be treated as the applicant and is capable of making decisions about their own care i.e. they have the mental and emotional development to make sound decisions, then Newlife will treat the child/young person as the applicant.

Parent/Carer’s DetailsThe details given below should relate to someone who will take responsibility for the loaned equipment, following a successful application. Care should be given in line with the terms and conditions listed within this application form.

First Name Family Name

House No. & Street

Town County Postcode

In order to progress this application please provide a daytime telephone number and email address that you check regularly. Providing additional numbers will ensure we can contact you in case of queries.

Tel (daytime): Tel (mobile):

Tel (home): Email:

Can you speak English? Yes No Your preferred language:

Have you previously used any of Newlife’s services? Yes No

If ‘No’, please tell us how you heard about Newlife:

Professional The Media Publication/Leaflet

Internet Exhibition Other (please specify)

Is the child/young person living at the same address as you?If ‘No’ please explain further:

Yes No

Is the equipment requested, for use at a different address than the child’s home?If ‘Yes’ please provide the address:

Yes No

Does your child/young person live in a: House Bungalow Flat/Apartment Other (please specify)



Is this property: Rented Owned by you/your partner Other (please specify)

How would you describe the child/young person’s family situation?

Living with both parents (include step-parents) Living mainly with one parent

Living with care given, at different locations, by both parents Other (please specify)

Has your home been adapted to meet the child/young person’s needs? Yes No Not applicable

Have you received a Carer’s Assessment?If ‘Yes’, did you receive any additional care/support following the assessment?

Yes No

By informing us of this information, if you are eligible for a carer assessment but haven’t had one, we can provide written information about how gain an assessment. Would you like more information?

Yes No

As the child/young person’s main carer, are you receiving any of the following types of support (tick all that apply):

Day Respite Night Respite Short Breaks Early Help Portage Family Support Worker

Special Needs Groups Holiday Play Schemes After School Club We are keen to ensure that parent/carers are accessing appropriate levels of support.

Do you have paid carers visit your home to support you in looking after the child/young person? If ‘Yes’, how is this care funded:

Yes No



Parent/Carer Demographic InformationThis information helps us to shape our services and support communities throughout the UK. We also use information within our fundraising applications to demonstrate the support we provide. Any decision to withhold information will not affect the progress of your application.

Gender Male Female Prefer not to say

Age 0-24 years 25-64 years 65+ years Prefer not to say

Religion or belief

No religion Islam

Christianity Sikhism

Buddhism Other religion

Hinduism Prefer not to say

Judaism

Ethnic background

White English/Scottish/Welsh/NI

Irish

Gypsy or Irish traveller

Any other white background

Mixed Mixed ethnic background

Asian/Asian UK Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background

Black/African /Caribbean/ Black UK

African

Caribbean

Any other Black/African/ Caribbean background

Other Arab

Any other ethnic group

Prefer not to say

Child/Young Person’s Demographic Information

Is the ethnic background, religion or belief of the child/young person different to the Parent/Carer? Yes No If ‘Yes’, please specify:

Need Support Or Information?Want To Speak With A Newlife Nurse?Newlife’s Care Services Team readily use confidential translation services. We want you to feel comfortable when raising sensitive questions or discussing important matters.

Simply call (free from UK mobiles and landlines) and inform a Nurse of your preferred language.

Newlife Nurses will provide caring emotional support and useful information regarding: · Access to health & social care professionals.· Rights & benefits.· Local & national services.· Delivery of care in the community.· Rare & complex conditions.

0800 902 0095



First Name Family Name

Date of Birth D D / M M / Y Y Y Y Gender Male Female Prefer not to say

National Insurance Number NHS Number

Is the child/young person fostered, placed in a residential school or residential care? Yes No

Has a public appeal, in the name of this child, been active to fund equipment or other benefits, in the last two years?

Yes No

Is the child/young person subject to a Medical Negligence Claim or Award?If ‘Yes’, have payments for medical compensation been received or being sought?

Yes No Yes No

Does the child/young person receive continuing health care (CHC) funding? Yes No

If they are old enough to do so, can you describe how the child/young person gets about? If too young to move around independently, do not select an option. Walk unaided Walk using aids Unable to walk Crawl Other (please specify):

Can the child/young person maintain head control by themselves? Yes No

Can the child/young person bear their own weight? Yes Partially No

Does the child/young person have: (please tick all that apply and provide details regarding the severity to which they affect daily life)

Any spine, limb or hip problems, which affect their walking or sitting?

Poor muscle control in any part of their body?

To be hoisted to transfer between positions?

Any difficulties with breathing?

Epileptic seizures? If so, please record the extent to which these are controlled.

Any type of digestive, stomach or bowel problems?

Problems with their sight?

Problems with their hearing?

Child/Young Person’s DetailsThis section is designed to capture the details of the child/young person who will be using the equipment. The minimum eligibility requirements for an Emergency Equipment Loan - the short-term loan of urgently needed equipment - are that the child/young person is a permanent UK resident, has a significant disability that affects their daily life (including a life threatening/limiting condition or has been diagnosed as terminally ill) and is under 19 years of age.



Relevant to their age, does the child/young person have difficulty with: Speech? Toileting? Sleeping? Understanding danger?

Would you say, or have you been told, your child has a problem with their behaviour?If ‘Yes’, please identify if a behavioural management plan has been developed to support the child and give information about how well it is implemented.

Yes No

If deemed relevant to this application, would you be happy to share a copy of the child/young person’s behavioural management plan?

Yes No

If ‘Yes’, this will be specifically requested and does not need to be provided when submitting this application.

Does the child/young person have any allergies or sensitivities?If ‘Yes’ please list below:

Yes No



Please tell us about the child/young person’s condition, diagnosis or disability:

Is it considered to be a: Life limiting condition? Life threatening condition? Terminal illness?

Please provide additional information to help us understand the cause of the condition, diagnosis or disability:

Is your child/young person awaiting hospital admission for surgery or tests? Yes No

Is the child/young person currently in hospital? Yes No

Is equipment needed for hospital discharge? If ‘Yes’, please provide a discharge date:

Yes No Don’t know

Does the child use the services of a Hospice? Yes No

Does the child/young person attend school? If ‘Yes’, what’s the name of the school?

Yes No

If old enough to attend a school, does the child/young person go to a: Mainstream school Mainstream school and has support/extra/special lessons Mainstream school and uses a special unit Attends a special school Is educated in a different way, please give details:

Is the child/young person’s education: Independently funded Local authority funded Unsure

Diagnosis And ServicesNewlife retains the right to capture more information through a short telephone interview if there isn’t enough detail provided within this application form, in order to authorise the costs associated with the loan. Therefore, it is worthwhile noting that the quality of information provided in this application form will directly affect the pace at which we can provide the Equipment Loan.



Does the child/young person have an Education, Health and Care Plan (EHCP)?If ‘Yes’, when is it due its annual review:

Yes No

If deemed relevant to this application, would you be happy to share a copy of the child/young person’s EHCP?

Yes No

If ‘Yes’, this will be specifically requested and does not need to be provided when submitting this application.

Which professionals have provided care to this child/young person in the past two years? Please give their role and where possible, details of their employer and the care setting within which they deliver care; e.g. Physiotherapist, funded by NHS, delivering treatment in school.

Please give the name of the child/young person’s General Practitioner, surgery name, address and their telephone number:

Is there currently a Social Worker involved in the child’s care?If ‘Yes’, please provide contact details:

Yes No

Are there any safeguarding concerns related to this child/young person?If ‘Yes’, please give details that are relevant to this application for equipment:

Yes No

If ‘Yes’, please state if they are: Current concerns Historical concernsPlease provide additional details about the extent to which any current or historical concerns are relevant to this application:

As an organisation that isn’t directly involved in the child’s care, a historical perspective of safeguarding concerns can be helpful when understanding the reason for this application.



Please tell us about the equipment that the child/young person currently uses on a daily basis, and how it was funded.

Please tell us about the equipment that you wish to loan:

Please provide details of the make/model of the piece of equipment the named professional (provided later in the application) has specified for the child/young person:

The specification details of our emergency loan suite, and live availability of this equipment, can be found at www.newlifecharity.co.uk/eel

Please provide details why this application is urgent?

Please tell us how the child/young person is affected by not having this equipment:



Please tell us how you believe the child/young person will benefit if they had this equipment:

If we are unable to provide an emergency equipment loan, can we contact you to discussusing this application form to provide an Equipment Grant?

Yes No

Have your local Health or Social Care Services already offered you equipment, that you have not accepted?If so, please state the reason for not accepting:

Please identify if there are any reasons why you wouldn’t want us to discuss this application with local NHS and Social Care Services.

Unless it is clear that doing so would be detrimental to the child/young person, Newlife collaborates with those organisations that have a statutory responsibility, enshrined in law, to meet the needs of children with disabilities.



EquipmentNHS Employed Professionals

Local Authority Employed Professionals

Beds (health needs)

Enclosed beds (safety needs)

Toilet bath/shower aid

Wheelchairs

Buggy

Seating

Mobile hoist

Supporting Professional’s DetailsWho Is The Most Appropriate Supporting Professional?The ideal circumstances are set out below – and will give an idea regarding which organisations should take responsibility for assessing a child/young person’s needs. Generally speaking, if the child/young person needs equipment to support postural needs then the support of an Occupational Therapist or Physiotherapist is required. Medical needs can be supported by Specialist Nurses and Safety/Behavioural needs can be supported by Social Workers – but they must be appropriately qualified (or supported as part of a multi-disciplinary team) to identify the correct specification of equipment.

If you do not have access to the support provided by one of these organisations, we may accept the support of a qualified professional involved in the child/young person’s care from education or charitable organisations – or following an independent assessment – but only if this application is preceded by a conversation with a Newlife Nurse. Simply call 0800 902 0095 to explain the circumstances as to why a local NHS or Social Care Professional can’t be named on this application – we will offer support to access a service, or agree to alternative arrangements to ensure timely provision.

In providing the details of a supporting professional providing care to the recipient child, please ensure that the professional named below is aware of your application as they will be needed to complete an additional form that confirms the suitability of the equipment specification and provides information that confirms the child’s eligibility for this service.This additional form will be provided by Care Services once this application is received.



What is the name of the professional supporting this application?

What does this professional do?

Who is their employer?

What is their telephone number?

What is their email address?

It is vital that we have an email address for the named professional so that we can share a copy of this form with them, and request an additional form is completed. If this additional form is not completed, an Emergency Equipment Loan cannot be provided.

Has this professional been informed that you are applying to Newlife? Yes No

Has this professional carried out an assessment of the child/young person’s needs? Yes No

Please describe the extent to which this named professional provides direct ongoing support to the child/young person:

Has this professional carried out an assessment of the child/young person’s needs? Yes No

Has this professional carried out a risk assessment regarding use of the equipment? Yes No

Please be aware that in order to be compliant with the General Data Protection Regulations (2018) then you must have received as a minimum verbal confirmation from the professional, to be named below, that they are willing to have their details shared with Newlife.


1. All the information given in this application process is accurate and representative of the need for this service.

2. Newlife is not obliged to make provision in respect of this application and all loans are at the discretion of Newlife.

3. To use the Equipment until you have received the initial training which will be provided by one of our designated agents or a qualified health professional. We need you to agree to always follow all instructions and recommendations provided to you, by us or the manufacturer or supplier of the Equipment. This training will cover, amongst other things, health and safety aspects and guidance for looking after the Equipment during the Loan Period and is necessary to ensure that the Equipment will be safe and without risk to health and safety when properly being used by the child/young person.

4. Newlife only loan the equipment for around 6 months. Within this 6 month period, if you no longer need the Equipment, you should tell us as soon as possible and we will arrange for the Equipment to be collected from your home. This will usually be within 3 working days but we will agree a date suitable for you. If you need it for longer than 6 months we will liase with you and your professional regarding an extension or change of provision.

5. Tell us if the equipment becomes unsuitable for your child to use due to changes in need or circumstances. We reserve the right to reassess the individual needs of the child, and potentially alter provision to receive an equipment grant rather than equipment loan.

6. Understand that the equipment remains the property of Newlife and we retain the right to recall the equipment. This notice would normally be, but does not need to be, given in writing.

7. Newlife will insure against all loss, theft or damage to the Equipment; public liability; and product liability whilst

you are in possession of the Equipment. Our insurance covers the Equipment whilst it is in the United Kingdom and for up to 90 days in other countries of the European Union. For use outside of these conditions, you will need to contact us to get approval. Under these circumstances, you may need to personally insure the item. You need to understand that you may also be held responsible, if you seriously misuse the Equipment or use it whilst it is knowingly faulty.

8. To take all reasonable steps to ensure that the Equipment is properly looked after. If the Equipment is lost or stolen whilst it is in your possession then you must let us know as soon as possible. We need you to agree to contact us directly if something goes wrong with Equipment (including, if the Equipment is damaged) whilst it is in your possession. We will arrange for Equipment to be inspected and repair or replaced.

9. Newlife the Charity for Disabled Children are the ‘Controllers’ of the personal data and health information we collect. We need to collect and process certain information to allow us to provide any of the named Care Services below. To see Newlife’s full privacy notice, please visit www.newlifecharity.co.uk

10. In the process of arranging delivery of equipment owned by Newlife, it is implicit that we must share personal information with trusted third-party companies who deliver this service to your home. Our agreements restrict their ability to use this data outside of the intended purpose for which it was provided.

11. The Equipment is provided to you as a charitable act. We will therefore only be responsible for any loss or damage that you suffer in connection with this Agreement, to the extent that we are able to claim for such loss or damage under our insurance.

Conditions Of An Emergency Equipment Loan In making this application you are agreeing to:


Family Declaration

By ticking the statements below and signing this form, I____________________________________(name of parent/carer) agree to the terms and conditions of the grant (as stated above), confirm that the provision is necessary and essential to support the named child within this application, and also confirm that this child meets the following criteria:

A permanent UK resident.

Has a significant disability which affects their daily life, a life threatening/life limiting condition or has been diagnosed as terminally ill.

Under 19 years of age.

Signature Date

Newlife Centre, Hemlock Way, Cannock, Staffordshire WS11 7GF. Newlife the Charity for Disabled Children - Registered Charity Number: 1170125 in England & Wales

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Email: [email protected] Nurse Chat: www.newlifecharity.co.uk/live

Lines open Monday-Friday 9:30am-5pm & Wednesdays until 7pm plus 24 hour answerphone (Free from UK mobiles and landlines)

If you HAvE ANy quESTIoNS, PLEASE CoNTACT our CArE SErvICES for frEE oN:

0800 902 0095