Group Session

Group Session

Registration Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email*
example@example.com
We understand that some clients may face financial challenges. End of Life Nursing Care is committed to promoting access to our services. If you find yourself in economic hardship, please reach out to discuss potential financial assistance options. Our goal is to ensure that everyone, regardless of financial circumstances, can receive the support they need during difficult times. All inquiries and discussions regarding financial assistance will be treated with utmost confidentiality and sensitivity."

I would like to apply for Financial Assistance

Application for Financial Assistance
Your well-being is our priority, and we are committed to providing support to those facing financial challenges. To ensure a fair and efficient process, please complete the application form with all requested information. Honesty and completeness are essential for a thorough assessment.

Please note that failure to provide honest and complete answers will result in the denial of your application. We appreciate your openness and understanding as we work together to offer assistance during these challenging times.
Describe your Martial Status*

I am SingleI have a partner but we don't live togetherI have a partner and we live together
Do you care for any dependents?*

NoYes
If yes, how many dependents under the age of 18 are you responsible for?

Describe your Employment Status*

UnemployedSelf-EmployedEmployed Full TimeEmployed Part TimeEmployed on Casual/Seasonal BasisI am unable to work and receive Social Assistance
If employed, how long have you been with your current employer?
Name of Employer*
Address of Employer*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone Number*
Please enter a valid phone number.
Employer's Email *
example@example.com
What is your Monthly Net Income? (Include all sources including Social Assistance)*
What is the average you spend on Monthly Expenses? (Rent, Groceries, Utilities)*
If you have assets, please provide the value. (Savings, Investments, Property). If none, please insert "0"
If you have loans or credit cards, what is the monthly payment you currently make? If none, please insert "0"*
Briefly describe the circumstances leading to the need for assistance*
Attach relevant documents such as pay stubs, bank statements, proof of expenses, and any other documents that support the financial situation outlined in the application.*

Cancelof
Consent to Verification*

I hereby grant consent for the verification of the information provided in this application for financial assistance. I understand that verification may involve contacting relevant institutions or individuals to confirm the accuracy of the details provided.I do not consent. I understand that providing consent for verification is voluntary. However, choosing not to consent may result in delayed application approval and may impact the eligibility for benefits.
Declaration of Accuracy*

I verify the above information provided, to the best of my knowledge, is accurate and up to date. I understand that by providing misleading or false information will lead to my application and request for services being denied.
Signature*

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Group Session

Application for Financial Assistance