Financial support/ Apply for a funding - Form

Please fill in the following form and submit your request

Application deadline: APRIL 30th 2018

1. USER IDENTIFICATION






Female Male

2. AUTHORIZED PERSON MAKING THE REQUEST




Female Male


3. SUBVENTION REQUEST FOR : 
Shadow support Other
4. CONCERNING THE USER
Combined with another impairment:
VisualHearingOther
Physical : need help for walkingUses a wheelchair
5. SELF-CARE SKILLS OF PERSON WITH IMPAIRMENT
Communication
Spoken Non-verbal
Easily With difficulty
Eating/Dressing
The person can :
unaided with help totally dependent
unaided with help totally dependent
unaided with help totally dependent
Getting around
Person can move:
unaided with help totally dependent
unaided with help totally dependent
Personal Care
For the personal hygiene, the person is :
autonomus needs help totally dependent
No wears a diaper
6. HEALTH
7. BEHAVIOUR PROBLEMS
Yes No
Directed toward self :
Yes No
Yes No
Yes No
Aggression toward others: :
Yes No
Yes No
Yes No
8. ABOUT FAMILY
Yes No

Yes No
Please, specify any SPECIAL conditions that may have a significant impact on family life that you want to inform the selection committee - Specify :
9. DID YOU VERIFY IF THE SERVICE COULD BE PROVIDED FOR A LOWER COST? (EXAMPLE, BY VOLUNTEERS)
Yes No
10. IF YOU RECEIVE ONLY A PART OF THE SUBVENTION, CAN YOU REALIZE THAT PROJECT?
Yes No
11. IF NOT, WHAT WOULD HAPPEN?
12. DID YOU MAKE AN APPLICATION TO ANOTHER PROGRAM SUBVENTION?
Yes No


Give the name and phone number of the other organizations to whom you have send a request. What was the answer?
 
Ext :
Ext :
13. DETAILS OF THE SERVICE COST
Funding requested calcuation:
x
x
x
=
+
+
=
-
-
=
If you receive a subvention, the check will be payable to



14. IDENTIFICATION OF THE COUNSELLOR/EDUCATOR






*NOTE :IF YOU DO NOT RECEIVE SERVICES FROM AN EMPLOYEE OF CISSSMO, YOU MUST ATTACH A COPY OF THE DIAGNOSIS OF THE USER.
Additional documents required
Documentation confirming that the household gross income, as shown on line 150 of the Canada Revenue Agency (CRA) Notice of Assessment, is less than $70,000.
If you do not receive services of an intervenant from CISSSMO, you must join a copy of the doctor’s diagnosis explaining the deficiency of the person concerned by the request.
CONFIRM AND SUBMIT
I have read and understood the criterias and conditions listed above and I commit myself to respect them. A misrepresentation or omission to declare sums received from other sources will involve the radiation of any future request made to the Foundation.

IN CASE OF A CHANGE OF RESSOURCE FOR WHOM I GOT A GRANT, I AGREE TO OBTAIN THE APPROVAL OF A FRAS REPRESENTATIVE TO MAKE SURE THAT I CAN USE THE MONEY GRANTED TO ANOTHER END.

Also, once the request is accepted, I commit myself to provide in the six months following the service a receipt, a copy of invoice or a proof of spent, written by the company or the person which provided the service.


Check to confirm the statement above