The MeidaHart Family Sponsorship

The MediaHart Family Sponsorship is availalbe for individuals who wish to participate in Hope Haven programs and meet the following two requirements:

Has a recognized disability or social-emotional need, supported by a regulated health professional.
Has a household income level that falls below the low income cut off levels as determined by the government of Canada.

Up to $300 is available per participant on an annual basis. On approval of application the funds will be directly applied to your Hope Haven account.

Participant Name

First Name Last Name

Participant Date of Birth

Date

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Applicant Name

First Name Last Name

Applicant Phone Number

Please enter a valid phone number.

Applicant's Relationship to Participant

Disability or Social-Emotional Need Verification

A regulated health care provider is required to complete Hope Haven's Professional Referral Form indicating the participant's disability or unique need that makes them appropriate for Hope Haven services and therefore a potential recipient of this sponsorship. The online form can be found on Hope Haven's website under Applications.

From the applicant's perspective, indicate the participant's disability or unique need that makes them appropriate for the services at Hope Haven.

Income Verification

Following review of your application, proof of income will be required to be shown in person prior to acceptance. Please have ready your most recent Notice of Assessment OR 3 recent pay stubs OR social assistance docuements (ODSP, Ontario works, EI).

Choose the appropriate option that indicates your household unit and income level before taxes.

1 person; Income $23,000 or less 2 people; Income $28,000 or less 3 people; Income $35,000 or less 4 people; Income $42,000 or less 5 people; Income $48,000 or less 6 people; Income $54,000 or less 7+ people; Income $60,000 or less

Number of adults in household

Number of children in household

Agreement

By applying for financial assistance, as the participant or the parent/legal guardian of the participant, I understand and accept the following terms and conditions:

All of the above information is true to the best of my knowledge and I am prepared to provide verification with required documents.
I have an obligation to attend the programs that have been confirmed for me.
I agree to pay the remainder of my invoice after the assistance has been depleted.
The assistance is valid for the current calendar year. I must wait until the following calendar year in order to reapply.

Applicant Signature

Clear

Date Signed

Thank you for your application. We will be in touch when it has been fully processed.