funding application

The Pink Pilates Trust allocates funds to women within 2 years of their cancer diagnosis who would not be able to participate in the Pink Pilates programme without financial assistance. The Pink Pilates Trust funding allocation system ranks women with the greatest financial and physical need on a regional basis. You will then be put on a waiting list depended on where you are ranked in your region.

The physical need is determined by the type of surgery, the type of cancer treatments, presence of any post-operative complications and/or pre-existing musculoskeletal problems and whether there has been a medical referral.

The financial need is determined by the combined household income, the number of dependant children, and whether women have had to stop working.

Each region has their own separate waiting lists which is determined by the funding available in that region.

Please fill in the assistance form below to help us better understand our Pink Pilates clients and hopfully obtain more funding for the Pink Pilates Programme:

(required form fields are bold)
First Name:
Last Name:
Email address:
Phone number:
Address:
Date of Diagnosis:
Date of Surgery:
Region:
Physio Clinic Name:
Question 1:
Age at your last birthday?
Less than 20 years old
21 - 39 years old
40 - 54 years old
55 - 65 years old
65 years and over
Question 2:
Ethnicity?
European/New Zealander
Australian
Maori
Pacific Islander
Asian
Aboriginal
Indian
Other
Question 3:
Have you had to stop work due to your cancer surgery or treatments?
Yes
No
Question 4:
Have you been able to return to work to the capacity you did before your diagnosis?
Yes
No
Question 5:
Type of Cancer?
Breast Cancer
Bowel Cancer
Secondary Breast Cancer
Lung Cancer
Gynaecological Cancer
Lymphoma
Other
Question 6: (select all that apply)
Please indicate all the types of cancer treatment you have had already or need to have?
Hormone therapy
Chemotherapy
Radiation therapy
Question 7: (select all that apply)
What type of surgery have you had?
None
Mastectomy/lumpectomy
TRAM or LAT Reconstruction surgery
IMPLANT reconstruction surgery
Oophorectomy
Axillary node dissection
Colorectal surgery
Brain surgery
Other
Question 8: (select all that apply)
Have you had any post op complications?
No
Seroma
Lymphoedema
Frozen shoulder
Poor/delayed wound healing
Surgical complications
Question 9: (select all that apply)
Please indicate if you currently have any difficulties from any of the following?
Swelling
Osteoporosis
Cording
Arthritis
Post operative pain
Fatigue
Headaches
Knee problems
Diabetes
Back or neck pain
Question 10:
Please indicate what your combined annual household income is.
Question 11:
How many dependent children do you have?
Question 12: (select all that apply)
Please indicate any goals you have from the Pink Pilates Programme.
Improve flexibility
Improve strength
Improve posture
Improve fitness level
Improve energy levels/manage fatigue
Improve feelings of well being
Reduce pain
Weight maintenance
Other
Question 13:
How did you find out about the Pink Pilates Programme?
Breast Nurse referral
Doctor or Surgeon referral
Cancer support referral
Website
Friend or family
Brochure
Advertisement
Other
Security Number:
Enter Security Number: