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Confirmation

In order to successfully complete and submit this form, please be sure to review the checklist below to make sure you have all of the supporting documents available, as you will need to upload all of the documents below, or you won’t be able to submit your form.

Supported file formats: PDF, DOCX, PNG, JPG
Size Limit 10MB per file.

Checklist of forms required:
1. A letter of support: a letter from the Grandview Kids clinician documenting the requirement of the equipment or tool being requested.
2. Quote/Receipt: A quote and/or receipt from a company or service provider that would be providing the equipment or tools. (Receipt must be no more than 1 year since purchase date).

Who Filled Out The Form

Client First Name

Client Middle Initial

Client Last Name

Date of Birth

Select the Day and Month then edit the Year.

Alayacare Client Number

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Client

email (Please check your spam or junk email folder if you don't see a confirmation email in your inbox)

Additional Parent First Name (Optional)

Additional Parent Last Name (Optional)

Full Address

Phone Number

Previously Received Funds?

NoYes

Date Previous Funds Received

Total Amount Requested (CAD)(<$2000)

Please enter the amount requested without the dollar sign ($)

If you are approved, how would you like your funds deposited?

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