HLF Eliminating Barriers Request Form

Number of HDSB students in your school needing support*

Please list only students enrolled at HDSB schools from a single household at one school.

Student's first name and last initial (do not provide full name)*

If this request is for more than one student in a household, please include all of their first names or initials.

2nd student's first name and last initial (do not provide full name)*

If this request is for more than one student in a household, please include all of their first names or initials.

3rd student's first name and last initial (do not provide full name)*

If this request is for more than one student in a household, please include all of their first names or initials. If there is not a 3rd student, please type in NA.

4th student's first name and last initial (do not provide full name)*

If this request is for more than one student in a household, please include all of their first names or initials. If there is not a 4th student, please type in NA.

The HDSB student/s needs help with (please check all that apply for this request)*

FoodClothingHygiene/BasicsSchool Teams (Please submit a separate request for each student from different households)Field Trips/Co-op (Field trips are for reimbursement only).Transport (Only select if requesting a reimbursement).Post-secondary applications (Only select if requesting a reimbursement).

Is this the first request for this student or household since August 15, 2024?*

YesNo

Please tell us a little about the student or household and their situation*

To ensure you receive support for the student as quickly as possible and to help reduce contact, we encourage ordering virtual cards. A virtual card will be sent to you as a pdf, which can either be: (a) printed for the student/family and provided to them in person; or (b) emailed or texted to the family. The family or student can print out or show the .pdf on their phone at the store checkout. Virtual cards usually take 3 school days to arrive.

If you select the physical card option, a team member at HLF will contact you about a location for picking up the cards.

Walmart cards cannot be requested for transportation, field trips, teams, or post-secondary applications.

I am requesting*

Virtual Walmart Card (max. $250 per student)-Virtual cards are emailed directly to you and take 3 days to arrive.Physical Walmart Card (max. $250 per student)-Physical cards must be picked up.Reimbursement (max. $250 per student, please list amount in the Reimbursement Amount space below)

Card Amount per HDSB student

Maximum of $250 per HDSB student

Reimbursement Amount

Maximum of $250 per HDSB student

Total Amount Requested for this household*

Please note that the maximum per student is $250.

If you chose the reimbursement option, HLF will reimburse the school, not the household or requester directly.

Please upload both a signed HLF cheque requisition form and accompanying receipts in the box below. The request for reimbursement is to be net of any HST rebate made on purchases.

Both a cheque requisition and proof of payment are needed to process a reimbursement.

Please attach a copy of the the signed cheque requisition, as well as a field trip form, invoices, receipts or other back-up here.

Today's Date

What’s next? You will receive an email with an Eliminating Barriers Tracking number and instructions about when you can expect the virtual card to be emailed to you or how to receive a physical card.

We respond to requests within one school day. If you do not hear back from us within 24 hours, please contact Kelly Sweeting at sweetingk@haltonlearningfoundation.ca.

Please verify that you are an employee of HDSB*

Stories of students may be shared with donors and potential donors with no identifying information included.

Eliminating Barriers to Learning Request Form for HDSB Students