Accessibility Funding Application Form

Current Request
Financials
Expenses
Other
Consent
Complete

Applicant

First Name

Last Name

Mobile Phone

Street Address

City

Postal Code

Province

Are you currently in Hospital or Rehabilitation?

Yes

Request

Please describe your disability

Item/Service Request

Please describe the item(s) or service you are requesting support for. If there are multiple items, please outline them using a numbered list and in priority.

Total Expense

What is the total expense of the item(s) or service(s) you described above?

Amount Requested

Please upload a quote that will assist your application

One file only.
15 MB limit.
Allowed types: pdf jpeg jpg png.

Impact

Please describe how this item or service will impact or enhance your independence, self-reliance and/or full community participation.

Self Funding

In the event your request is partially funded, are you willing to fund some of the expense on your own?

Yes

Self Funding - Amount

If you answered yes to the above question: How much are you able to contribute?

Funding - Other Sources

Have you applied for funding for this request through other funding sources?

Yes

Funding - Other Sources - Details

If you replied yes to the above question, please provide details including how much you've requested and the date you should receive a response. If you have already received funding, please indicate the amount received.