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Application Form
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2024-02-10T16:10:46+00:00
Request for Assistance
Referred By:
Must be a medical professional.
First name
*
Last name
*
Phone number
*
Email
*
Occupation
*
Why, in your opinion, does this family require financial assistance?
*
Child's Information:
First name
*
Last name
*
Street
*
City
*
Province
*
- Province -
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
*
Date of Birth
*
Sex
*
Illness
*
Mother's information:
First Name
Last name
Phone Number
Father's information:
First Name
Last name
Phone Number
Additional Information:
Preferred Correspondence Language
*
English
French
Email Address
*
Is the client on Social Assistance? (If yes, contact the case worker)
*
Yes
No
As a family why are you in need of financial assistance from the Sick Children's Fund?
*
Please indicate the items for which you need assistance:
Travel
Prescription Drugs (Prescription Required)
Please attach the prescription
*
Choose File
Medical Equipment (Prescription or Doctor's Letter Required)
Please attach the prescription or doctor's letter
*
Choose File
Other
Please specify:
*
If accepted, what would be the preferred method for receiving the funds?
*
Cheque
INTERAC e-Transfer
Unknown
Email Address for INTERAC e-Transfer
*
By submitting this application, the FUND understands you are applying for assistance and you are also granting us permission to talk to the child's doctor, social worker, caseworker or any relevant party to determine the level of required assistance.
*
I understand and give my permission
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