Physical Safety of Child / Medical Treatment

FAMILY SUPPORT FUND APPLICATION

This fund was created to support Holland Bloorview clients who need financial help to support their health and well-being during exceptional circumstances. The more you can tell us, the better we can help! To be considered for funding, you must:  Be a registered client of Holland Bloorview  Have had a medical appointment with Holland Bloorview in the two years prior to the date on this application  Be under the age of 19  Complete every section of this application form (*Incomplete forms will be returned*) Funding Guidelines  Funding limits and criteria are subject to change at appropriate review intervals  Funding maximum is $1000.00 per client, per year ( April 1 st , 2015 to March 31 st , 2016)  Applications submitted in the months of February and March will be held until April 1st  The maximum level of funding will not be available to all of our applicants  If you need help, please call your Social Worker or a Family Support Specialist at 1-877-463-0365  You will receive a letter of approval or denial within 3-6 weeks from the date we receive your completed application form. Equipment Medication  Maximum of $1000 per year  Maximum of $1000 per year  Provide a quote or invoice  Provide an quote from the pharmacy  Provide a letter of support from a member of  Provide a letter of support from a member of your care team your care team Transportation Costs / Taxi Voucher Family Accommodations  Maximum of $1000 per year  Maximum of 22 nights in a Studio or 15 nights  Calculated at a rate of $0.45 per kilometer in a Suite  Provide an estimate based on the distance  Funding is calculated on a number of nights between your home and Holland Bloorview rather than a dollar amount  Provide an estimate for a flat rate from the cab  Provide a letter of support from a member of company your care team  Provide a letter of support from a member of your care team In-Home Respite Worker Recreation / Camp / Respite Program  Maximum of $500 per year  Maximum of $500 per year  Respite must be provided by a recognized  Provide a quote or invoice Respite Service Provider  Provide a description of the program  Provide a letter of support from a member of  Provide a letter of support from a member of your care team your care team Agreement with Holland Bloorview Kids Rehabilitation Hospital To ask for money from the Holland Bloorview Family Support Fund, you must also agree to these terms. Make sure you understand these terms before you sign. 1. In making this request for funding, you are giving Holland Bloorview permission to speak to the organizations and individuals provided in this application. 2. Holland Bloorview is not responsible for any harm that might come from your request for money. 3. Holland Bloorview is not taking part in your agreement with people or companies for equipment or services. 4. You will not ask Holland Bloorview to pay you back for any harms that arise from people or companies who sell you equipment or services. 5. Holland Bloorview does not make suggestions for people or companies who might help you. 6. If Holland Bloorview gives you money or help, it does not imply that the equipment or services are good or right for you. I have read the above Agreement with Holland Bloorview Kids Rehabilitation Hospital and I agree to it. I confirm that the information provided in this application is true, correct and complete to the best of my understanding. Parent/Guardian Signature: ______Date: _____/______/______Day Month Year The personal information you give us on this form allows us to administer the Family Support Fund. We collect, use and share this information under the authority of the Public Hospitals Act. If you have questions, please contact the privacy office at 416-425-6220 ext. 3467 or [email protected].

General Information

Client’s Name: ______Date of Birth: ____ /____ /_____ Last Name First Name Day Month Year

Parent’s Name: ______(Guardian) Last Name First Name Relationship to the Child

Address: ______

City: ______Province: _____ Postal Code: ______

Home Phone (incl. area code): ______Work / Cell: ______

Email Address: ______

If you are helping this family fill out the application, please indicate your:

Name: ______Organization: ______

Job Title: ______Phone: (____) ____- _____ Ext: _____ Email: ______

Funding Information: I am requesting funds to help cover the cost of: Equipment In-Home Respite Worker Transportation Costs / Taxi Voucher Medication Family Accommodations Recreation / Camp / Respite Program

A.) Estimated Cost of Equipment/Service: $ ______B.) Other Funding Received for this Item: $ ______C.) Requested Amount ($1000 maximum) $ ______

Is this is a Holland Bloorview program? Yes No

Please check the main clinical program area(s) that your child has used within the past 2 years Cleft Lip & Palate & Craniofacial O.T., P.T., S.L.P. Communication & Writing Aids Pediatrician Feeding and Saliva Clinic Prosthetic and Orthotic Inpatient – BIRT Psychology Inpatient – CCC Psychopharmacology Clinic Inpatient – SODR Seating Clinic Lifespan Social Work Neuromotor Spina Bifida & Spinal Cord Service Neuromuscular Therapeutic Rec. & Life Skills What is the level of financial need? THIS MUST BE FILLED OUT Have you applied to the following funds for this item or service:

Easter Seals Yes No If No, Why Not? ______President’s Choice Children’s Charity Yes No If No, Why Not? ______Jennifer Ashleigh Children’s Charity Yes No If No, Why Not? ______Ontario Federation for Cerebral Palsy Yes No If No, Why Not? ______March of Dimes Yes No If No, Why Not? ______Jump Start Yes No If No, Why Not? ______Employee Health Benefits Yes No If No, Why Not? ______Other: ______Yes No If No, Why Not? ______

Have you applied to the Family Support Fund this year (April 1st /15–March 31st /16)? Yes No If yes, how much did you receive? $ ______

Check off your family’s current yearly income: Under $25,000 Between $25,000 and $45,000 Between $45,000 and $70,000 Between $70,000 and $95,000 Between $95,000 and $150,000 Over $150,000

Please check the statements that best describe your situation: I am receiving social assistance (Ontario Disabilities Support Program, Ontario Works, or Assistance to Children with Severe Disabilities) There are no other funding options available for this item / program I have other funding options but this item / program is very expensive I have a moderate or significant income but lots of expenses due to my child’s disability

Tell us more about your financial situation to help us fully understand why you are applying for funding to cover the cost of this item or service: ______

What is your Marital Status? ______

How many people are in your family? ______Physical Safety of Child / Medical Treatment Check the statement which best describes how the item or service helps keep your child safe or supports their physical wellbeing: It is necessary for my child’s physical safety It will help prepare my child for transition home. (e.g. taxi for inpatient leave of absence) It will provide physical support and stability It will help to support participation It has limited or no impact on physical safety or physical well-being of my child Tell us more about your child and how this money will help with physical safety and support rehabilitation goals.

______

Well-Being of the Family / Child Check all of the statements that apply: There is a need for parental relief and support Parental job loss Single parent family We have other medical / health issues in the family (Explain below) We have more than one child with special needs It will provide my child with an opportunity for fun and / or social activity Tell us more about the areas of stress in your life and how this item / program will help the well-being of your child and family.

______To Complete the Application Process Mail, fax or drop off this completed application form to:

Family Support Fund, Family Resource Centre Holland Bloorview Kids Rehabilitation Hospital 150 Kilgour Road Toronto, ON M4G 1R8 Fax: (416) 425-6376 Tel: (416) 425-6220 ext. 6303