Apply for Financial Assistance

Who is filling out this application?*

Community or HealthCare Professional

Name

Relationship to Child

Organization Name/Agency Name

Phone

Child and Family Information

Child*

First Last

Birthday*

Gender

Your Email Address*

Enter Email Confirm Email

Medical Diagnosis*

What care facility or hospital has your child received treatment from?*

Is your child currently staying in hospital?*

Parent #1:*

Parent #2

Legal Guardian

Marital Status*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Secondary Phone

Does this child live with you?*

Number of people living in the child's home*

Ages of siblings

Who lives in your home other than your children?*

Purpose of Funds

Please indicate which category of funding you'd like to apply for, if applicable. In the space below, please state the item you're requesting. If you request more than one item, please state which one is most critical.*

Household Costs (Child needs to be a current inpatient to qualify)

Therapy

Respite

Hospital Costs

Medication/Medical Supplies

Other-please specify below

Items:*

Have you contacted or applied to any other organizations for this request?*

Yes

Please list the organizations that you have contacted and their reply*

Financial Information

What is your household total annual income? We assess this by looking at line 15,000 of your CRA Notice of Assessment

Parent #1*

Parent #2

Guardian*

Do you recieve Employment Insurance?*

Yes

Monthly Amount

Do you recieve Child Support?*

Yes

Monthly Amount

Are you a new resident to Ontario?*

Yes

Ontario Works (OW) Monthly Amount received:*

Ontario Disability Support Program (ODSP) Monthly Amount received:*

Temporary Care Assistance Monthly Amount received:*

Assistance to Children with Severe Disabilities (ACSD) Monthly Amount received:*

Special Services at Home (SSAH) Monthly Amount received:*

Canadian Child Benefits (CCB) + Ontario Child Benefits (OCB) Monthly Amount received:*

Has your family work status or income changed over the past year?*

Yes

How does this impact your financial situation?*

Child's Monthly Expenses

List the monthly amount ($) for each expense that is not covered by another organization. The expense must be for the child named on this application and be related to their medical diagnosis.

Transportation (excluding parking) $

Meals/Accommodation $

Medication or Special Formula recommended by medical doctor $

Disposable medical supplies $

Therapy (speech, occupational, or physiotherapy) $

How did you hear about us?

Have you applied to us in the past?*

Yes

When?

DOCUMENTS THAT MUST BE UPLOADED

The following documents must be uploaded/included with your Application: Licensed Canadian Medical Practitioner’s Diagnosis Letter, Notice of Assessment(s) – Require page with line 15000 only (total income) Assistance to Children with Severe Disabilities (ACSD) stub/statement (If NO ACSD is received, we need proof of income for each parent) OPTIONAL: letter form social worker, Quote from vendor or supplier- if applicable

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Upload your documents (ABOVE) in .pdf, .doc or .docx format

AUTHORIZATION/RELEASE FOR THANK YOU LETTERS AND PHOTOS

We love to receive letters and photos from the children and families that we assist. It is important for JACC to be able to communicate with our supporters and donors, what life is like for your sick child and for you as a family. We like to feature stories of children in our newsletters, letters to donors, on Facebook, Twitter and our website, and in the plaques that we present to our supporters. Please indicate below if the Jennifer Ashleigh Children’s Charity may use any photos, children’s artwork, or thank you letters that you send to us along with your child’s first name, age, and nature of their illness. This is for awareness and promotional purposes only. Be assured if your letter is used, only first names will appear. Any last names or addresses will not be used.

Newsletters, letters to donors, Facebook, Twitter, website and presentation plaques*

Yes

Would you or your child be interested in speaking occasionally about your JACC experience at fundraising events or with media to benefit JACC?*

Yes

I certify that the information provided on this application is true, correct, and complete to the best of my ability.*

Agree

Signature (please type your name here)*

Privacy Policy

The Jennifer Ashleigh Children’s Charity Privacy Policy makes every effort to ensure that any individual’s personal information is protected and properly handled. The information you provide on this application is only used for the purpose of determiningRevised April 12, 2019 eligibility. It is reviewed and handled by only those designated and authorized to do so within the Jennifer Ashleigh Children’s Charity office. For a full version of our Privacy Statement please visit: www.JenAsh.org If your application is granted and a file is created, your secure file will be stored at our office location for five years (for audit purposes) before being shredded. Minimal information is also kept indefinitely on our secure database. If you have a concern or inquiry regarding our Privacy Policy or our privacy practices please call our office at (905) 852-1799 ext. 21 or email generalmail@jenash.org

Apply for Financial Assistance

Application for Financial Assistance 2023

Community or HealthCare Professional

Child and Family Information

Purpose of Funds

Financial Information

Child's Monthly Expenses

DOCUMENTS THAT MUST BE UPLOADED

AUTHORIZATION/RELEASE FOR THANK YOU LETTERS AND PHOTOS

Privacy Policy

Important Information

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