
<p> Light Up A Child’s Life The Calgary Cerebral Palsy Association Funding Request Application</p><p>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]</p><p>Section A PERSONAL INFORMATION</p><p>Name of Applicant (person whom funding is for): ______</p><p>Applicant’s date of birth (DD/MM/YY): ______</p><p>Applicant’s Address: ______</p><p>City / Province: ______Postal Code: ______</p><p>Applicant’s Phone #: (_____) ______</p><p>How long has the applicant been a member of the CCPA? ______</p><p>Parent(s)/Guardian(s) Name(s), if applicable: ______</p><p>Parent(s)/Guardian(s) Address, if different from above: ______City/Province:______Postal Code:______</p><p>Parent(s)/Guardian(s) phone #: home (_____) ______work (_____) ______</p><p>Upon approval, cheque will be made payable to:</p><p> Applicant Parent or Guardian, named above other, please specify ______</p><p>Section B (complete this section if you are applying for funding for: DSA skiing, camp, horseback riding, or adapted bicycles.)</p><p>I am applying for funding for: DSA skiing Camp Adapted bicycle</p><p>Description of equipment/program/services requesting funding for: ______</p><p>Cost: $______GST: $______Total: $ ______</p><p>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</p><p>Description / name of equipment: ______</p><p>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.) ______</p><p>Has the equipment been purchased and paid for? yes no If yes, please attach a copy of the receipt(s).</p><p>For equipment requests, you must include 3 price estimates. Have you done so? yes no If not, please explain. ______</p><p>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? ______</p><p>Do you have any private insurance that would cover some or all, or part, of the cost for this equipment? yes no</p><p>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:</p><p> Volunteering at the casino Collecting and/or donating silent auction items</p><p> Assisting organizing events Sitting on the Board other, please specify </p><p>______</p><p>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.</p><p>Signature of Applicant/Parent/Guardian: ______Date (DD/MM/YY):______</p><p>**office use only** Approved yes no Date: ______Amount: ______</p>
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