Easter Seals Equipment Funding Application

Easter Seals Equipment Funding Application

You are filling and signing Easter Seals Application. These fields will automatically fill the application.

GENERAL INFORMATION:

Parent/Guardian Name
Parent/Guardian Name
First Name
Last Name
Please Note: Email is our primary method of communication for Easter Seals Services (equipment funding and recreation). Please provide email to receive correspondence faster. If no email is provided, you will receive all correspondence by mail.
Child’s Name:
Child’s Name:
First Name
Last Name
If you are unsure of your Easter Seals ID#, please leave blank
Have you received Easter Seals’ funding previously?
If no, please ensure the child is a registered client with Easter Seals Ontario. If you are receiving funding from the Incontinence Supplies Grant Program, you are not automatically a client of Easter Seals Ontario. Please contact the office to confirm eligibility if you are unsure.
For statistical purposes only, please indicate your total household income:
Please specify type (ex- wheelchair, walker, bath chair, etc.) ONE PIECE OF EQUIPMENT PER APPLICATION PLEASE.

VENDORS AND SOURCES OF FUNDING:

Note: Vendors MUST be a registered business and located in Ontario
Employer Extended Health Care Benefits:
Other Agencies:

BREAKDOWN OF EQUIPMENT FUNDING REQUEST:

$
Write in total amount from preferred Vendor Quote
$
Write in Amount Approved (if applicable)
$
Write in Amount Approved (if applicable)
$
Write in Amount Approved (if applicable)
$
Write in Amount
$
Write in Amount

AUTHORIZATION AND SIGANTURES:

I instruct and authorize Easter Seals Ontario to provide and release any information to following vendor after Easter Seals Ontario has approved funding for the equipment being requested in this application.
Would you like your prescribing Therapist or a support worker to be included in all correspondence regarding this request?
I understand and agree that Easter Seals Ontario may carry out inquiries for the purpose of confirming or clarifying the information submitted, processing the application, addressing an appeal, or with any other agency listed on this application form. I further understand and agree that these inquiries may require exchange of information that may take the form of electronic data exchanges.

I certify that the information provided in the application is true, correct, and complete to the best of my ability, and that the equipment has NOT been received (exception- communication lease). If you have received the requested piece of equipment, you are NOT eligible to apply for Easter Seals Equipment Funding.

Please initial that you have read and understand the above statement and are NOT in possession of the requested equipment
I will indemnify and save harmless Easter Seals Ontario its employees from and against any and all expenses related to all claims, demands, liabilities, losses, costs, damages, actions, suits or other proceedings of any nature or kind whomsoever sustained, brought or prosecuted in any manner based upon, occasioned by or attributable to the negligent act or omissions or the willful or reckless misconduct of the vendor/contractor, in the fulfillment of utilizing the funds provided by Easter Seals Ontario. Easter Seals Ontario acts as a third-party funder and as such has no role in prescribing, recommending equipment, selecting a vendor/contractor and in the relationship between the parent and vendor. Payment from the Equipment Funding Program is not an acknowledgement that the work or equipment was acceptable.
Please review this form to ensure all information and supporting letters/documentation is provided. If any information is missing, the application will be returned for completion, resulting in a delay in processing the request. Please keep a copy of the completed form for your files.

Easter Seals Check List – Request for Equipment Funding

You do not need to submit this sheet with your application. This is for your reference only.
ALL APPLICATIONS MUST INCLUDE:
Wheelchairs, walkers, and standers must include:
AFO’s, KAFO’s, computers, communication devices and leases must include:
Accessibility aids (portable lifts, porch lifts, track lifts, ramps), bathroom equipment (bath aids, commodes, transfer aids) must include:
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