AFU Request to Pay

Parent Name

First NameMiddle NameLast Name

Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

ADDRESS

Street Address Line 2

CITY/TOWN

POSTAL CODE

Child Name

First NameMiddle NameLast Name

DATE OF BIRTH (yyyy/mm/dd)

Date

Is this a child in the care of the ministry?

PAYMENT TO BE PROVIDED TO

AGENCY NAME

Address

City

Postal Code

Clinic Phone Number

Service Provider(s)

Types of Services

If not sure, just put Behavioural Intervention

Start Date

End Date

Date

Fee

For multiple services, just put the highest amount. Fee Information: https://cherishclinic.com/project/fees/

Per

TOTAL AMOUNT

I consent to use the child’s autism funding for up to the total amount for services or other purchases noted on this form.

Signature

Date Signed

Date

Cherish Clinic will review the form and submit on your behalf.

Please enter your email here to receive a copy of the PDF, so you never have to redo all the standard information again!

Autism Funding Unit