LEAF Application - The Ontario Federation for Cerebral Palsy

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
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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: leaf@ofcp.ca
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