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Thank you for joining the Walking with Brandon Foundation’s Therapy and Beyond multi-disciplinary rehabilitative program.

Terms and Conditions
Privacy Policy

New Client Sign Up Form

Thank you for joining the Walking with Brandon Foundation’s Therapy and Beyond multi-disciplinary rehabilitative program.

Your details will be shared with the appropriate practitioner(s) to start you on your rehabilitative journey.

Name

Please indicate which types of rehabilitation you require:

Practice Type: *

Biokinetics

Physiotherapy

Occupational Therapy

Speech Therapy

Hydrotherapy

Peer Support

General Details

Subsidy or medical aid/private funding *

Subsidy

Medial Aid/Private Funding

Referring Practitioner *

Title *

First Name *

Surname *

Identity Type *

Identity/Passport Number *

Disability Type *

Email Address *

Mobile Number *

Home Number *

Work Number *

Alternative Contact Number *

Alternative Contact relationship *

The Walking with Brandon Foundation (WWBF) relies on funding from various corporate sponsors. Your de-identified information may be used for reporting, business planning, or investment proposals and may be passed on in a de-identified format to third parties for information purposes. Your permission in this regard is highly appreciated and given by signing this form.
The WWBF is an accredited training facility for interns and will participate in research programs from time to time.
The practitioners are contracted to the WWBF but run their own independent practices within the Therapy and Beyond Centres. All accounts and billing will be done under their own practice numbers directly to you. The subsidy program operates under special arrangements between the practitioners and WWBF. As such, your practitioner will need to share certain information with the WWBF to claim your subsidy pending your permission.
The practitioners operating in the Therapy and Beyond Centres all carry their own malpractice insurance.
The WWBF fully complies in full with the requirements of the POPI Act. Our Privacy Policy and Terms and Conditions can be found in the footer on our website.
Children under the age of 18 will require a guardian to sign on their behalf.

FULL NAMES *

DATE *

I hereby acknowledge that I have read and understood the above information as well as Terms and Conditions and the Privacy Policy.

I have also been given the opportunity to ask questions by calling Mark Beack on 083 456 3006 prior to having signed this application, and acknowledge that all information submitted by me is true and correct.

Consent Form (Sharing of Personal Information)

The POPI Act compels us to comply with the new regulations effective 1st July 2021.

Please assist us to facilitate this process by completing the below form and thereby giving permission to your practitioner/s to share it with the Walking with Brandon Foundation’s information officer for record-keeping and marketing purposes.

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General Information

First Name *

Surname *

Mobile Number *

Home Number

Work Number *

Email Address *

The Walking with Brandon Foundation (WWBF) relies on funding from various corporate sponsors. Your de-identified information may be used for reporting, business planning or investment proposals and may be passed on in a de-identified format to third parties for information purposes. Your permission in this regard is highly appreciated and given by signing this form.
The practitioners are contracted to the WWBF but run their own independent practices within the Therapy and Beyond Centres. All accounts and billing will be done under their own practice numbers directly to you.
The practitioners operating in the Therapy and Beyond Centres all carry their own malpractice insurance.
The WWBF complies in full with the requirements of the POPI Act. Our Privacy Policy and Terms and Conditions can be found in the footer on our website.
Children under the age of 18 will require a guardian to sign on their behalf.

I hereby acknowledge that I have read and understood the above information as well as Terms and Conditions and the Privacy Policy.

I hereby acknowledge that I have read and understood the above information as well as Terms and Conditions and the Privacy Policy. A copy can be requested by emailing popia@walkingwithbrandon.org.

I have also been given the opportunity to ask questions by calling Mark Beack on 083 456 3006 prior to having signed this consent form and acknowledge that all information submitted by me is true and correct.

All your personal documentation and information transferred to us by your practitioner/s will be managed in line with the stipulations of the POPI Act.

FULL NAMES *

DATE *

I hereby give my practitioner/s consent to transfer my documents and information to the WWBF’s information officer.

Subsidy Programme

Subsidy Programme Application Form

Less than 20% of South Africans have medical aid, meaning that the vast majority of the population depends on government funding for healthcare. With little access to long-term rehabilitation, few people reach the full potential of their physical abilities.

The Walking with Brandon Foundation (WWBF) strives to develop the facilities and knowledge required in South Africa to properly provide for the long-term rehabilitative needs of all individuals with neurological disabilities. Our philosophy is to first provide you with the most advanced and effective physical rehabilitation and then help take you BEYOND what you previously thought your body is capable of.

In light of these goals, subsidised sessions for the financially restricted are offered at our Therapy and Beyond Rehabilitation Centres.

Subsidy Programme Application Process

An applicant is required to submit the following documents:

A doctor’s report of injury/disorder and clearance for moderate to vigorous exercise.
A one-page motivational letter describing why you need physical rehabilitation and what goals you would like to achieve.
An affidavit confirming your financial status, along with:
- Your latest salary slip and 3 months’ bank statements of patient (if unemployed, then the highest earning individual in the immediate family);
- A list of immediate family assets (property, vehicles etc.) and value; and
- The total monthly household income and a list of dependents on this income.
Patients approved for the Subsidy Program will receive a maximum of 12-weeks of rehabilitation before having to submit a motivation letter to the Walking with Brandon Foundation’s Subsidy Program of motivating the need to continue rehabilitation. You will need to acquire this letter and information from your practitioner and submit it to the WWBF.
The outcome of your application and your financial contribution towards your rehabilitation will be decided within 10 working days of receipt of your application and accompanying documentation.
The Walking with Brandon Foundation’s PR team media team may require that you share your story and experience of the program as a means of promoting the WWBF and Therapy and Beyond Centres. This content may be shared across multiple platforms such as television, radio and social media and we will require you to sign a separate consent form giving us this permission.

Name

I hereby acknowledge that I have read and understood the above information as well as terms and conditions and the Privacy Policy .

I have also been given the opportunity to ask questions by calling Mark Beack on 083 456 3006 prior to having signed this consent form and acknowledge that all information submitted by me is true and correct.

Personal Details

First Name *

Surname *

ID Number *

Contact Number *

Email Address *

Postal Address *

Access to Transport *

Yes No

Employed *

Yes No

If employed then type of employment

Personal monthly income (wages/grants/interest etc.) *

Total monthly household income *

Number people living on household income *

List of family assests and value *

Terms and Conditions

Please upload the following documents:

Copy of identity document *

Motivational letter *

Doctor’s letter of condition/disability & medical clearance for exercise *

Your latest salary slip (OR highest family earner if you are unemployed) *

Three months’ bank statements (OR highest family earner if you are unemployed) *

Signed police affidavit stating own monthly income, household family income and list of household assets and value *

The confidential and sensitive information collected in this application may be transferred to third parties for the purpose of funding applications and/or reporting.

I hereby give consent to the use of my information.

SIGNED AT: *

DATE: *

Consent Form (Sharing of Personal Information)

The Walking with Brandon Foundation’s Subsidy Program has undergone a restructure and at the same time the POPI Act has compelled us to comply with the new regulations as of 1st July 2021. Our POPI Act Privacy Policy can be viewed here.

Alternatively, you can request a copy by emailing POPIA@walkingwithbrandon.org.

All your personal documentation and information transferred to us during the application process will be managed in line with the stipulations of the POPI Act.

By signing below, you consent to transfer your personal documents and information to the WWBF’s Subsidy Program and to the appointed practitioner as discussed with you.

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FULL NAME: *

DATE: *

SIGNED AT: *

I hereby give consent to the use of my information.