Ontario Federation for Cerebral Palsy LEAF Application Form - 2015 Complete this application form in full. Date:_____________________ Year / Month / Day Attach all required documentation. Individual Membership ID#: _____________ (Applicant) Print in pen, submit to OFCP by postal mail, Applicant’s Information Incomplete applications will be returned. fax or email Name (who the activity is for): ______________________________________________________ First Name Last Name Date of Birth:_____________________ Diagnosis: Year / Month / Day Cerebral Palsy Address: ______________________________________________________________________ City: ___________________________________________ Postal Code: ___________________ Home phone: _________________________ Bus. Phone: ______________________________ Email: ________________________________________________________________________ Primary Contact (if applicable) Name of Primary Contact: _______________________________________________________ (parent or guardian required if the applicant is under 18 years) First Name Last Name Relationship to applicant:__________________________________________________________ Address: ______________________________________________________________________ City: _________________________________________ Home phone: _________________________ Postal Code: ___________________ Bus. Phone: ______________________________ Email: ________________________________________________________________________ Life Enriching Activity I am applying for: _______________________________________________________________ Duration of Activity From:________________________ To _______________________________ Year / Month / Day Year / Month / Day In what way(s) would this activity enrich your life? ______________________________________ ______________________________________________________________________________ Do we have permission to use your story in our promotional material (facebook, newsletter, etc...) Yes__ No__ Page 1 of 4 April 2015 Funding Summary LEAF Funding Request Summary Note: The OFCP will fund one activity up to a maximum of $500 per member per application period. Item Amount ($) Line 1 Estimated total cost for activity Line 2 Total funds requested from the OFCP Office Use Only Please Make Cheque Payable to: Check one of the following: Applicant / parent / guardian Activity provider Name: __________________________________ Name of provider: _________________________ Address: ________________________________ Address: ________________________________ ________________________________________ ________________________________________ Relationship with applicant: ________________ Phone number: ___________________________ Checklist (please complete before submitting your application) You must be able to answer YES to all of the questions below prior to application Yes No Have you read ALL of the guidelines and eligiblity criteria including who can apply? After reading ALL the guidelines, do you qualify? Have you included a price quote/estimate? (required) Have you included information about the activity? (required) Have you been an OFCP member for a minimum of 12 months (or 6 months for children ages 5 & under) Have you included; 1) an invoice from the activity provider? OR 2) paid receipt for the activity? (not required for initial application, but is required upon approval) Financial Need (Check off your household yearly income) Under $20,000 Between $25,000 and $45,000 Between $45,000 and $70,000 Between $70,000 and $95,000 Over $95,000 Please explain your financial circumstances to help us understand why you are applying for LEAF: ______________________________________________________________________________ ______________________________________________________________________________ Page 2 of 4 April 2015 Life Enriching Equipment ASSISTIVE DEVICES FUNDING PROGRAM ASSISTIVE DEVICES FUNDING PROGRAM Equipment/Item/Material Requested: _______________________________________________ Equipment/Item/Material Requested: _______________________________________________ ___ No___ No ___ Has above equipment / item / material been ordered or received? Yes Yes___ Has above equipment / item / material been ordered or received? Yes___ No___ Is Item Covered by ADP?: Yes_______ No _______ Amount Covered $ _________________ Is Item Covered by ADP?: Yes_______ No _______ Amount Covered $ _________________ Documentation Required. If ‘Yes’, have your prescribing Health Professional (ie: Occupational or Physiotherapist) Documentation Required. If have Health Professional (ie: or Documentation Required. If ‘Yes’, ‘Yes’, Confirmation have your your prescribing prescribing Health Professional (ie: Occupational Occupational or Physiotherapist) Physiotherapist) complete enclosed ‘ADP Approval Sheet’ and submit with application. If ‘No’, attach your Health complete enclosed ‘ADP Approval Confirmation Sheet’ and submit with application. If ‘No’, attach your complete enclosed ‘ADP Approval Confirmation Sheet’ submit with application. ‘No’,orattach your Health Health Professional’s current authorization indicating the need and for the requested equipment,Ifitem material. Professional’s current authorization indicating the need for the requested equipment, item or material. Professional’s current authorization indicating the need for the requested equipment, item or material. 1. Name of Vendor ________________________________________ Quote $ ______________ 1. Name of Vendor ________________________________________ Quote $ ______________ 2. Name of Vendor ________________________________________ Quote $ ______________ 2. Name of Vendor ________________________________________ Quote $ ______________ Documentation Required - Attach copies from listed vendors. Documentation Documentation Required Required -- Attach Attach copies copies from from listed listed vendors. vendors. Cost of the Equipment/Item/Material: $ ________________________ Labour/Installation) Preferred Vendor’s Quote Cost of(Excluding the Equipment/Item/Material: $ ________________________ (Excluding (Excluding Labour/Installation) Labour/Installation) Preferred Preferred Vendor’s Vendor’s Quote Quote Other Funding you have accessed: If yes to any, please attach agencies/insurance company’s Other Funding you have If yes any, please attach agencies/insurance company’s letter and the amount thataccessed: will or will not be to covered. letter and the amount that will or will not be covered. Ontario Disability Support Program (ODSP) Yes _______ No _______ N/A _______ Ontario Disability Support Program (ODSP) Yes _______ No _______ N/A _______ Yes _______ _______ No Employer Extended Health Care Benefits Yes No _______ _______ N/A N/A _______ _______ Employer Extended Health Care Benefits Yes _______ No _______ N/A _______ Yes _______ _______ No Private Insurance Yes No _______ _______ N/A N/A _______ _______ Private Insurance Yes _______ No _______ N/A _______ Other Agencies Yes YesMinistry _______ _______ No No _______ _______ N/A N/A _______ _______ (ie. Service Clubs, Local Community Groups or Businesses, of Education) (ie. Service Service Clubs, Clubs, Local Local Community Community Groups Groups or or Businesses, Businesses, Ministry Ministry of of Education) Education) (ie. Complete the calculation box below which applies to your request - purchase or lease Complete the calculation box below which applies to your request - purchase or lease Purchase Equipment/Item/Material - Calculation of Request for Financial Assistance Purchase Equipment/Item/Material - Calculation of Request for Financial Assistance A) Estimated Cost of Equipment/Item/Material $ ________________________________ (Excluding Labour / Installation) Preferred Vendor Quote A) Estimated Cost of Equipment/Item/Material $ ________________________________ (Excluding Preferred (Excluding Labour Labour // Installation) Installation) Preferred Vendor Vendor Quote Quote B) ADP Approved Amount $ ________________________________ B) ADP Approved Amount $ ________________________________ Approved Amount Approved Amount Amount Approved C) Employer Extended Health Care Benefits $ ________________________________ Amount (attach letter if applicable) C) Employer Extended Health Care Benefits $ ________________________________ Amount Amount (attach (attach letter letter ifif applicable) applicable) D) Insurance $ ________________________________ D) Insurance $ ________________________________ Amount (attach letter if applicable) Amount (attach (attach letter letter ifif applicable) applicable) Amount E) Other Agencies $ ________________________________ Amount (attach letter if applicable) E) Other Agencies $ ________________________________ Amount Amount (attach (attach letter letter ifif applicable) applicable) F) Total Remaining $ ________________________________ F) Total Remaining $ ________________________________ A-B-C-D-E=F A -- B B -- C C -- D D -- E E= =F F A TOTAL REQUESTED FROM OFCP $ ________________________________ TOTAL REQUESTED FROM OFCP $ ________________________________ Lease Equipment - Calculation of Request for Financial Assistance Lease Equipment - Calculation of Request for Financial Assistance A) Total Annual Cost to Lease Equipment /Item $ ________________________________ A) Total Annual to Of Lease $ ________________________________ NotCost Total Cost Item Equipment /Item Statment of Account / Invioce Not Total Total Cost Cost Of Of Item Item Not B) Other Agencies B) Other Agencies C) Total Remaining C) Total Remaining TOTAL REQUESTED FROM OFCP TOTAL REQUESTED FROM OFCP Statment of of Account Account // Invioce Invioce Statment $ ________________________________ Amount (attach letter if applicable) $ ________________________________ Amount Amount (attach (attach letter letter ifif applicable) applicable) $ ________________________________ $ ________________________________ A-B=C A A -- B B= =C C $ ________________________________ $ ________________________________ Amount Page 2 of 4 Page 2 4 Page 2 of of 4 4 Page 3 of Amount Amount December 2014 December 2014 December April 2015 2014 Indemnity I hereby indemnify and save harmless the Ontario Federation for Cerebral Palsy, its officers, directors, employees and agents from and against any and all claims, demands, liabilities, losses, costs, expenses, damages, actions, suits and other proceedings arising out of the activity described in this application. I understand that the Ontario Federation for Cerebral Palsy acts as a third party funder and as such has no role in choosing, recommending or selecting an activity and that any payment from OFCP LEAF program is not an acknowledgement that the activity is acceptable for the purposes intended. Privacy The OFCP collects, uses and discloses personal information related to this application only for the purposes of assessing, processing and administering this application and may exchange such information with the above-mentioned contact person, vendors, medical professionals and other agencies. I consent and (as applicable) confirm the user’s consent to this collection, use, disclosure and exchange of personal information. For additional information regarding the OFCP’s personal information protection privacy practices, please refer to our Privacy Policy on the OFCP website. Certification I certify that the information provided in this application is true, correct and complete to the best of my knowledge. By providing your signature below, as the applicant or applicants guardian, you are giving permission to OFCP staff to process your application accordingly. I confirm that I have read and understand all of the OFCP LEAF Program criteria & guidelines Signature: _________________________________ Date:_______________________________ Relationship to Applicant (if applicable): ______________________________________________ Please ensure all information and supporting documentation are provided. If any information is missing, the application will be returned to you for completion, resulting in a delay in processing the request. A copy of the completed form should be kept for your files. If you have any questions please contact: Ontario Federation for Cerebral Palsy 416-244-9686 ext: 222 or toll free 1-877-244-9686 ext: 222 Email: [email protected] Website: www.ofcp.ca Return the completed form by mail to: Ontario Federation for Cerebral Palsy LEAF Program 1630 Lawrence Avenue West, Suite 104 Toronto, Ontario M6L 1C5 FOR OFFICE USE ONLY Date Received _____________________________ File Number _______________________________ Page 4 of 4 April 2015
© Copyright 2024