The Calgary Cerebral Palsy Association

Light Up A Child’s Life The Calgary Cerebral Palsy Association Funding Request Application

This form must be entirely completed with all applicable documentation attached Please mail/fax/email to: Calgary Cerebral Palsy Association, #204, 8180 Mcleod Trail S. Calgary, AB T2H 2B8 Fax#: 403-253-8236 Phone#:403-205-4935 email: [email protected]

Section A PERSONAL INFORMATION

Name of Applicant (person whom funding is for): ______

Applicant’s date of birth (DD/MM/YY): ______

Applicant’s Address: ______

City / Province: ______Postal Code: ______

Applicant’s Phone #: (_____) ______

How long has the applicant been a member of the CCPA? ______

Parent(s)/Guardian(s) Name(s), if applicable: ______

Parent(s)/Guardian(s) Address, if different from above: ______City/Province:______Postal Code:______

Parent(s)/Guardian(s) phone #: home (_____) ______work (_____) ______

Upon approval, cheque will be made payable to:

 Applicant  Parent or Guardian, named above  other, please specify ______

Section B (complete this section if you are applying for funding for: DSA skiing, camp, horseback riding, or adapted bicycles.)

I am applying for funding for:  DSA skiing  Camp  Adapted bicycle

Description of equipment/program/services requesting funding for: ______

Cost: $______GST: $______Total: $ ______

Have you applied for similar funding before with the CCPA?  yes  no If yes, when and how much were you funded? ______Section C (complete this section if you are applying for funding for: adaptive computer equipment, adaptive home equipment, or other adaptive/assistive equipment or technology.) I am applying for:  adaptive computer equipment  adaptive home equipment  other adaptive/assistive equipment or technology

Description / name of equipment: ______

How will this equipment aid the person affected by cerebral palsy? (i.e., how it works, what it is used for, why/how would this equipment or technology be important to the individual affected by cerebral palsy.) ______

Has the equipment been purchased and paid for?  yes  no If yes, please attach a copy of the receipt(s).

For equipment requests, you must include 3 price estimates. Have you done so?  yes  no If not, please explain. ______

Are there other agencies or government departments that will fund, or partially fund, this equipment? (i.e., AADL, CSN, Blue Cross, etc.)  yes  no If yes, which agencies have you contacted and how much have you been or will be funded? ______

Do you have any private insurance that would cover some or all, or part, of the cost for this equipment?  yes  no

From time to time, the CCPA will need to call on you for your support. Please indicate areas in which you can offer your help and in what capacity:

 Volunteering at the casino  Collecting and/or donating silent auction items

 Assisting organizing events  Sitting on the Board  other, please specify

______

I hereby certify that all the information contained in this application is, to the best of my knowledge, accurate, true and complete in all respects. I understand that acceptance of this application and funding is under the complete discretion of the Board of Directors of the CCPA. I also understand this application will be returned if it is to be found incomplete in any respect.

Signature of Applicant/Parent/Guardian: ______Date (DD/MM/YY):______

**office use only** Approved  yes  no Date: ______Amount: ______