Financial Application Form 2026 CKFTO

Financial Application Form 2026 CKFTO

Apply for financial assistance with the Caribbean Kids and Families Therapy Organisation. Please complete all sections accurately. All information is confidential.
Mission Statement: The Caribbean Kids and Families Therapy Organisation (CKFTO) provides professional, compassionate therapeutic services to Caribbean children from birth to twenty-one years with special needs. In keeping with our non-profit mandate, CKFTO offers services on a sliding fee scale. The information provided in this application assists us in determining an appropriate fee for your child. All information is treated as strictly confidential. Applications are processed within one (1) week of submission. Applicants will be notified via email and/or telephone. For enquiries, please contact: (868) 628-3268 | info@ckfto.org

CKFTO is an NGO. The non-submission of the documentation requested WILL delay the qualification process. You MUST submit the requested paperwork for administration to determine if you qualify for financial assistance.
SECTION A: CHILD INFORMATION
Child’s Full Name

First NameLast Name
Date of Birth (DD/MM/YYYY)

MonthDayYear
Date
Age
Sex
Residential Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
School Name
School Address
Class / Grade
Diagnosis(es)
Type of Diagnosis (check all that apply)

Other
Health Insurance
Insurance Provider
Coverage Type
SECTION B: PARENT / GUARDIAN INFORMATION
Parent / Primary Guardian Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Sex
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
ID Number
DP Number
Passport Number
Country of Birth
Citizenship
Marital Status
Health Insurance
Provider / Coverage Type
Parent / Secondary Guardian Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Sex
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
ID Number
DP Number
Passport Number
Country of Birth
Citizenship
Marital Status
Health Insurance
Provider / Coverage Type
Relationship between parents/guardians
Additional caregiver involved?
If yes, Name & Relationship

Parent/Guardian Transport

Rows	Mother	Father
Private
Public

Is a parent/guardian unable to work due to the child’s disability?
If yes, please explain
SECTION C: EMPLOYMENT, INCOME & HOUSEHOLD EXPENSES
Parent / Primary Guardian Employment Status
Occupation
Employer
Monthly Income (after tax) (TTD)
Monthly Medical Expenses - Prescriptions
Monthly Medical Expenses - Medical Supplies
Monthly Medical Expenses - Pampers
Housing
Monthly Amount (TTD)
Other Monthly Expenses (food, transport, utilities, etc.)
Other Sources of Income
Therapy Expenses (company/NGO)
Parent / Secondary Guardian Employment Status
Occupation
Employer
Monthly Income (after tax) (TTD)
Monthly Medical Expenses - Prescriptions
Monthly Medical Expenses - Medical Supplies
Monthly Medical Expenses - Pampers
Housing
Monthly Amount (TTD)
Other Monthly Expenses
Other Sources of Income
Therapy Expenses (company/NGO)
Income verification (e.g., job letter, pay slip) - Upload

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SECTION D: CHILD THERAPY & RELATED EXPENSES

Therapy Services (Monthly)

Rows	Frequency	Monthly Cost (TTD)
Physiotherapy
Occupational Therapy
Speech Therapy
Developmental / Behavioural
Psychology
Music / Art / Recreational
Other

Other Monthly Child-Related Costs
School Fees
Adaptive Equipment
Medications / Supplements
Special Diet / Foods
Personal Care Items
Transportation
Other Specialized Care
Is the child toilet trained?
SECTION E: FINANCIAL HARDSHIP STATEMENT
Please describe your family’s financial circumstances and reason for requesting fee assistance
DECLARATION & SIGNATURE
I certify that the information provided is true and complete to the best of my knowledge. I understand that CKFTO may request further supporting documentation and that all information will remain confidential.
Signature
Date

MonthDayYear
Date
Printed Name

First NameLast Name
FOR OFFICIAL USE ONLY
Date Received

MonthDayYear
Date
Applicant Name

First NameLast Name
Applicant Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
ID Number
Preferred Therapy Location
Financial Assistance Approved
Tier Assigned
Approved By (Signature)
Should be Empty:

Financial Application Form 2026 CKFTO

SECTION A: CHILD INFORMATION

SECTION B: PARENT / GUARDIAN INFORMATION

SECTION C: EMPLOYMENT, INCOME & HOUSEHOLD EXPENSES

SECTION D: CHILD THERAPY & RELATED EXPENSES

Other Monthly Child-Related Costs

SECTION E: FINANCIAL HARDSHIP STATEMENT

FOR OFFICIAL USE ONLY