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Application for Assistance

Please fill out the form below and submit for consideration. We also require a doctor’s note confirming the diagnosis (1 page max.), as well as at least one quote for the item/camp/therapy you are requesting. Please scan and upload these documents, save them as “CHILDS NAME – DOCUMENT NAME” then send them to info@fortheloveofachild.ca

Date of Request*
MM slash DD slash YYYY
Amount of Request*
Child's full name*
Age of Child*
Address*
Street Address Address Line 2 City Province Postal Code
Contact Number*
Email Address*
Guardian 1*
Medical Diagnosis*
Equipment or Therapy*
Quote*
Enter the quoted cost or short quote details from the provider.
Reason for Request*
Social Worker (if applicable)
Name, Address, Phone Number of the company or individual who will be providing the service or item*
What other organizations have you applied to for funding? What was their response? (Note: Confirmation Required)*
File
Drop files here or

Max. file size: 256 MB.
Consent for website
I AGREE
If you would like your child to be featured on our website, please provide consent below and include the image with the additional documents needed for the application. I consent to For the Love of a Child to allow posting the image of our child, our child's name, and potentially the item we have requested to our website and social media.
Consent*
I AGREE
I certify that the information in this form is true and complete and does not contain a claim for any expenses previously paid for by this or any other organization. I authorize For the Love Of a Child, it's Agents and Service Providers to use and exchange information needed for approving this request.
Full Name*
Signature*
Date*
MM slash DD slash YYYY
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