March of Dimes HVMP Funding Application – Mobility Specialties Forms

Type of Funding Request

What are you requesting? (Explain in detail)

Is your request over $15,000?

Yes

No

If yes, please note that the Program will provide up to $15,000 for home and/or vehicle modifications. Please identify what person, agency or organization will be paying the difference: If yes, please note that the Program will provide up to $15,000 for home and/or vehicle modifications. Please identify what person, agency or organization will be paying the difference:

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

1. Is your home:

Owned

Rented

Owned by Family

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

Yes

No

Not Applicable

4. Is the equipment in the home on trial?

Yes

No

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)

yes

no

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

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 (Unit #, Street #, Street Name):

City & Postal Code:

Phone:

Email Address:

Marital Status:

married/common-law

separated

single

widowed

Source of Income:

CPP/OAS

ODSP/Ontario Works

GAINS

OtherOther

Please contact me in the following ways:

Email

Phone Call

Mail Only

Do not contact me, contact my Primary Contact Person below.

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.

First Name:

Last Name:

Pronouns:

Your relationship to the Applicant:

Mailing Address (Unit #, Street #, Street Name):

City & Postal Code:

Phone:

Email:

Please contact me in the following ways:

Email

Phone Call

Mail Only

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.

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)

to seek or maintain employment

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.).

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

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:

(First & Last Name)

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

Yes

No

Apply for March of Dimes HVMP Funding Applications

Type of Funding Request

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

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

Applicant Information:

Consent

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