Special Consideration Request – Vaccine Fee Relief

About this form

If you are not eligible for free vaccines under current guidelines but are experiencing hardship, you may request special consideration for fee relief.

Please complete the form below. All requests will be assessed on an individual basis.

Privacy Collection Statement

Your personal information is being collected by Wyndham City Council to assess your eligibility for special consideration for vaccine fee relief. The information will be stored and used by Council to identify you when communicating with Council and for delivery of services and information. You may apply for access and/or amendment of the information by writing to mail@wyndham.vic.gov.au. Your personal information will be handled in accordance with the Privacy and Data Protection Act 2014 (Vic). For further information about how your personal information is handled, please visit Council’s Privacy Policy.

I have read and understood the Privacy Statement mentioned above

Resident Details (the person requiring the vaccine/s)

Full name:

Date of Birth

Property Address

Preferred Contact Number

Email Address

Are you completing this form for another person (e.g. a child or dependent)?

Yes

Please provide your details:

Full Name

Your Relationship to the Resident (e.g. parent, guardian, carer) Contact Number

Contact Number

Email Address

By completing this section, you confirm you are authorised to provide this information on behalf of the resident.

Reason for Request

Please tell us why you are seeking fee relief:

Financial hardship affecting your ability to pay

Family or personal safety concerns

Large family requiring multiple vaccine record entries

Other:

Financial Hardship

Note: Residents applying for fee relief on the grounds of financial hardship should be aware that any approved waiver will be granted for a period of 12 months, after which a new application will be required.

Do you currently experience financial hardship that limits your ability to access healthcare services?

Yes

Please provide details

Please provide any additional information that may support your request:

Declaration

I confirm that the information provided is true and correct to the best of my knowledge.

What Happens Next

Your request will be assessed on a case-by-case basis within 14 business days.

We may contact you if further information is required.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.