March of Dimes HVMP Application

Type of Funding Request

The person with the disability is referred to as the “Applicant.” All questions should be answered by the Applicant or on their behalf. Please provide information for one Applicant per form.

Are you applying for:

Construction Home Modification Funding? (Accessible Bathroom, Accessible Entrance)

Non-Construction Home Adaptations and Device Funding? (Stairlifts, Porchlifts, Ramps, Ceiling Lifts)

Vehicle Modification Funding?

Both Home and Vehicle Modification Funding?

Home Modification Questions

Is your home:

Owned

Rented

If rented, do you have landlord permission to install the equipment being requested?

Yes

No

N/A

Have you recently moved from an accessible to inaccessible home?

Yes

No

Have you tried to look for other suitable accommodations?

Yes

No

Is the home you are requesting modifications to your permanent residence?

Yes

No

Vehicle Modification Questions

Is your vehicle:

Owned

Leased

To be Purchased

Does the driver of the vehicle have a valid driver’s license?

Yes

No

Are you requesting driving controls?

Yes

No

If yes, are you certified/approved to use the hand control?

Yes

No

What type of mobility device(s) are you currently using? (Check all that apply):

Are you currently working with an Occupational Therapist who is supporting your modification, adaptation, or device request?

yes

no

Are you currently working with a Equipment Supplier/Vendor, Contractor or Vehicle Modifier who is supporting your modification, adaptation, or device request?

yes

no

If this is a Construction Home Modification has the contractor viewed your home?

yes

no

If yes, when is the contractor available to start?

If yes, how long will the project take to complete?

Is your disability or request for modification the result of (check all the apply):

A workplace Injury:

Yes

No

A Motor Vehicle Collison:

Yes

No

Applicant Information:

This information helps us know how best to contact you about your application

Date of Birth:

First Name:

Last Name:

Preferred Name (if different):

Pronouns:

Mailing Address:

City & Postal Code:

Phone:

Email Address:

Marital Status:

Please contact me in the following ways:

Email

Phone Call

Mail Only

Do Not Contact Me

Please provide an Alternative Contact Person. This person can speak on your behalf, and we will not contact you about your application. I acknowledge that by listing an Alternative Contact Person below I will not receive any information or correspondence about the outcome of my application.

Alternative Contact Person:

If the Applicant is under the age of 18, an adult must be identified. If you are the Power of Attorney / Legal Guardian for the Applicant, enter your information here.

First Name:

Last Name:

Pronouns:

Your relationship to the Applicant:

Mailing Address:

City & Postal Code:

Phone:

Email OR Mailing Address

Please contact me in the following ways:

Email

Phone Call

Mail Only

Information About the Applicant

What is your disability?

How does your disability impact your mobility?

How will this modification, adaptation, or device improve your ability to complete activities of daily living (eating, bathing, toileting, transferring, and mobility) and/or getting in and out of your home to access essential medical care or community services?

Is the reason you need this modification because of employment?

Yes

No

If you received the modification, would you be able to seek or maintain a job?

Yes

No

Based on your answers above, what best describes your reason for needing the requested modifications, only select one.

remove or minimize a life safety risk

prevent hospitalization/institutionalization by assisting the individual to continue living safely in their home (with or without assistance)

allow discharge from hospital/institution by assisting the individual to continue living safely in their home (with or without assistance)

avoid loss of employment and income

allow a caregiver to meet the responsibilities of caring for a dependent with a disability (attend medical appointments, therapy, and community activities etc.).

to support both children and adults to participate in developmental/community activities (Examples: to attend school, church, volunteer work, community activities, etc.).

Additional Funding Sources
Please tell us about all the other funding sources which have been approached to help pay for the
cost of your modification requests, including your own or family contributions.
The program will provide up to $15,000 for home and/or vehicle modifications. Any remaining cost
above $15,000 listed on the quotes provided with your application will need to be listed.

Source 1

Name/Organization:

Amount:

Contact Information:

Source 2

Name/Organization:

Amount:

Contact Information:

Source 3

Name/Organization:

Amount:

Contact Information:

Permissions

I agree that March of Dimes Canada may contact me for the following reasons: (check all that apply)

Fundraising: To contact me about donating to March of Dimes Canada

Survey: To obtain feedback on services I receive from March of Dimes Canada

Opinion Poll & Research: To solicit my view on services or policies affecting people with disabilities

Receive Information: To advise me of new information, services or opportunities that may be of interest to me but are from third party companies, agencies, or service providers

Volunteer: To provide me with a volunteer opportunity

Do not contact me

Protection (Privacy) of Applicant Personal Information
Purpose
March of Dimes Canada (MODC) collects personal information for a variety of purposes including the delivery of services, fundraising, quality management, research, billing, and meeting legal and regulatory requirements.
MODC utilizes several safeguard measures to protect personal information and keep it confidential and will not share any personal information with any third parties unless it is directly related to the delivery or enhancement of the services that MODC provides or unless a Canadian law requires it.
Personal information that is no longer required to fulfill the identified purposes will be destroyed, erased, or made anonymous. MODC has guidelines and procedures to prevent unauthorized access and to govern the destruction of personal information
The full MODC Personal Information Protection (Privacy) Policy is available on the MODC website or by request.

Consent

I fully understand the reasons March of Dimes Canada (MODC) has requested my personal information and I give consent to MODC to use my personal information for the purposes outlined. I also understand that I may withdraw my consent at any time, subject to legal or contractual obligations and reasonable notice, and that MODC will inform me of the implications of such withdrawal.

Signature of Applicant:

Clear

Date

OR if signed by someone other than the applicant, please write your full name below:

I certify that I am the Applicant’s Power of Attorney or Substitute Decision Maker

I certify

Type of Funding Request

Home Modification Questions

Vehicle Modification Questions

Is your disability or request for modification the result of (check all the apply):

Applicant Information:

Information About the Applicant

Source 1

Source 2

Source 3

Permissions

Consent

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