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Application for Assistance

Eligibility Criteria:

Resident of Durham Region
Under 21 years of age
Formal diagnosis
Request must be for a specialized equipment or therapy

Fill out the form below and submit for consideration. Please include a quote from the service provider for the item/camp/therapy you are requesting funding for. Save this document as “CHILDS NAME – DOCUMENT NAME” then attached it to this form using the file attachment field.

Please note we do not provide funding for respite at this time.

Applications are reviewed every 2 months.

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
Home Phone Number*
Email Address*
Guardian 1*
Cell Number*
Guardian 2
Cell Number
Medical Diagnosis*
Reason for Request*
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)*
Do you receive special services at home?*
- Yes
- No
Do you have Extended Health Benefits through your Employer?*
- Yes
- No
File
Drop files here or

Max. file size: 256 MB.
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.
Consent
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.
Full Name*
Signature*
Date*
MM slash DD slash YYYY
CAPTCHA

Date of Request:

Do you receive special services at home?

Yes No

Do you have Extended Health Benefits through your Employer?

Yes No

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.

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.

I AGREE!