Apply for March of Dimes HVMP Funding Applications

Funding application for stairlifts, vertical platform lift, ceiling lift, elevator lift, automatic door opener, custom ramps, accessible home modification, accessible bathroom modification

*Please note that the online application service is designed to automatically fill out the PDF application form for you. It does not submit the application directly to March of Dimes. You will have the opportunity to download the completed application, which you can then send to March of Dimes. Additionally, a copy of the filled application will be stored on our server and shared with the email addresses you provide.

March of Dimes HVMP Application 2024

Type of Funding Request

What are you requesting?
Is your request over $15,000?

Must complete box for Home Modification requests. Please answer from the perspective of the applicant.

1. Is your home:
2. If rented, do you have landlord permission to install the equipment being requested?
3. Type of Home:
4. If you are applying for a bathroom modification, what floor is the bathroom on?

Must complete box for Vehicle Modification requests. Please answer from the perspective of the applicant.

1. Is your vehicle:
2. Does the driver of the vehicle have a valid driver’s license?
3. Are you requesting driving controls?
3a. If yes, are you certified/approved to use the hand control?

For all requests, please complete the following questions. Please answer from the perspective of the applicant.

1. Is your disability or project the result of a workplace Injury (check all the apply)
1. Is your disability or project the result of a Motor Vehicle Collison (check all the apply)

Applicant Information:

This information helps us know how best to contact you about your application
Marital Status:
Source of Income:
Please contact me in the following ways:

Primary Contact Person:

By listing a Primary Contact Person below I acknowledge I will not receive any information or correspondence about the outcome of my application and this person is authorized to speak and make decisions on my behalf.

Please contact me in the following ways:
Based on your preferred method of contact, please list a minimum of one of the following methods of communication:

What best describes your reason for needing the requested modifications, only select one.
I agree that March of Dimes Canada may contact me for the following reasons: (check all that apply)

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.
(First & Last Name)
I certify that I am the Applicant’s Power of Attorney or Substitute Decision Maker