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Confirmation

Before filling out this application, parents or guardians must first discuss the desired equipment or tool with their Grandview Kids clinician. The clinician will complete a recommendation form which will be available in the child's electronic health record.

Supported file formats: PDF, DOCX, PNG, JPG
Size Limit 10MB per file.

In order to proceed with the application, please verify the steps below are complete by checking the boxes.

The Family Support Fund recommendation form has been completed by my clinician. I have a quote or receipt from a company or service provider that would be providing the equipment or tool (receipt must be no more than 1 year old since purchase date).

Client first name

Client middle initial

Client last name

Date of birth

Select the day and month then edit the year.

AlayaCare client number

Parent/Guardian first name

Parent/Guardian last name

Relationship to client

Email (Please check your spam or junk email folder if you don't see a confirmation email in your inbox)

Additional parent/guardian first name (Optional)

Additional parent/guardian last name (Optional)

Full address

Phone number

Previously received funds?

NoYes

Date previous funds received

Total amount requested (CAD)(<$2000)

Please enter the amount requested without the dollar sign ($)

If you are approved, how would you like your funds deposited?

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Enter the code from the image