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Client Name*
First Last
Phone*
Address*
Street Address Address Line 2 City Province Postal Code
Date of Birth*
Month
Day
Year
Age*
Diagnosis*
Diagnosis Made By*
Please Provide Us With The Following Information Regarding Your Child:
Have applied for SSAH but not yet received funding*
- Yes
- No
Accessing other forms of respite funding (i.e. ACSD Respite Funding/MFTD Funding)*
- Yes
- No
Accessing out of home respite (i.e. Weekend Parent Relief Program/EAF Respite)*
- Yes
- No
More than one child/sibling in the home with an ASD diagnosis*
- Yes
- No
Received Autism Direct Funding Last Year*
- Yes
- No
This funding cannot be used for IBI/ABA/Speech/Occupational Therapy or Tutoring. Please provide details regarding the amount of funding being requested up to a maximum of $500.
Name of Camp*
Cost per Week*
Address of Camp*
Street Address Address Line 2 City Province Postal Code
Name of Camp*
Cost per Week*
Address of Camp*
Street Address Address Line 2 City Province Postal Code
Name of 1:1 Support Worker
First Last
Hours per week to be worked
Rate of Pay
Name of 1:1 Support Worker
First Last
Hours per week to be worked
Rate of Pay
Name of Skill Development Program:
Cost of Program

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