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Client Name
*
First
Last
Phone
*
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Name of Camp
*
Cost per Week
*
Address of Camp
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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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