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 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2007 2008 2009 2010 2011 2012

Date of Surgery: Date 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2007 2008 2009 2010 2011 2012

Region: Select the region nearest you... Northland Matakana Auckland Waikato Bay of Plenty Hawkes Bay Manawatu Taranaki Wellington Nelson Canterbury North Otago/South Canterbury Central Otago Dunedin Southland Sunshine Coast Brisbane Gold Coast Sydney Melbourne

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. Household Income under $50,000 $50,000 - $75,000 $75,000 - $100,000 $100,000 - $150,000 over $150,000

Question 11: How many dependent children do you have? Dependent Children none 1 or 2 3 or 4 more than 4

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

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