ADFP Application Form

Please note: Online application requires you to have all your documents in electronic format AND attach them at the bottom of this form

ADFP Application - 2021

Complete this application form in full. Attach all required documentation. Incomplete applications will be returned.

Fields marked with a red * are required fields

* If you require additional information regarding this application or have any questions please contact us.

Date

yyyy mm dd

Individual Membership ID # *

Note: Assistive Devices Funding Assistance is only available to Individual Members of the Ontario Federation for Cerebral Palsy.

Applicant's Information

Name (who the equipment is for)

First Name Last Name

Date of Birth

yyyy mm dd

Address

Street Address

Street Address Line 2

City Province

Postal Code

Home Number

Area Code Phone Number

Bus. Number

Area Code Phone Number

Email

example@example.com

Primary Contact (if applicable)

Name of Primary Contact (parent or guardian required if the applicant is under 18 years)

First Name Last Name

Relationship to applicant

Address

Street Address

Street Address Line 2

City Province

Postal Code

Home Phone

Area Code Phone Number

Bus. Phone

Area Code Phone Number

Email

example@example.com

Equipment

Equipment/Item/Material Requested

Has above equipment / item / material been ordered or received?

Yes No

Is Item Covered by ADP?

Yes No

If Yes to above question - amount covered $

Enter $ amount

An item that has been ordered or received does not guarantee approval of funding from this program.

Documentation Required: Health Professional current rationale letter for all items. If requested item is covered by ADP Ministry of Health and Long-Term Care, please have your health professional complete enclosed ADP Approval Confirmation Sheet and submit with application.

Name of Vendor # 1

Vendor # 1 Quote $

Enter $ amount

Name of Vendor # 2

Vendor # 2 Quote $

Enter $ amount

Documentation Required - You can attach electronic copies from listed vendors at the bottom of this form.

Cost of the Equipment/Item/Material $

Enter PREFERRED VENDOR'S QUOTE $ amount (Excluding Labour/Installation)

Other Funding you have accessed: OFCP requires that you approach applicable funding sources prior to, or in conjunction with, submitting your application to OFCP. Please check which funding sources you have already applied to:

Other Funding you have accessed: Please check which funding sources you have already applied to:

Applied

Approved - YES

Approved - NO

Response - VERBAL

Response - WRITING

Ontario Disability Support Program (ODSP)

Ontario Works

Local City Social Services

Assistance for Children with Severe Disability (ACSD)

Other

If OTHER above, please specify the source

(For possible other funding sources, please see attached Addendum A)

If response was in writing, please include a copy with this application.

Complete the calculation below which applies to your request.

Purchase Equipment/Item/Material - Calculation of Request for Financial Assistance.

A) Estimated Cost of Equipment/Item/Material

(Excluding Labour / Installation) - Preferred Vendor Quote - $ Amount

B) ADP Approved Amount

Approved Amount - $ Amount

C) Other Funding Obtained

1) Agency

Amount (attach letter if applicable)

2) Agency

Amount (attach letter if applicable)

3) Agency

Amount (attach letter if applicable)

D) Total Remaining (Calculation: A - B - C = D)

Amount in $

TOTAL REQUESTED FROM OFCP:

Amount in $ (max $2000)

When was the last time you received funding from ADFP?

Month Day Year

I have never received funding from ADFP

Never received ADFP funding before

Indemnity

I hereby indemnify and save harmless the Ontario Federation for Cerebral Palsy, its officers, directors, employees and agents from and against any and all claims, demands, liabilities, losses, costs, expenses, damages, actions, suits and other proceedings arising out of the supply of the equipment described in this application. I understand that the Ontario Federation for Cerebral Palsy acts as a third party funder and as such has no role in prescribing, recommending equipment, selecting a vendor/contractor or in the relationship between the purchaser and vendor of the equipment and that any payment from the OFCP Assistive Devices Funding Program is not an acknowledgment that the equipment is acceptable for the purposes intended.

Privacy

The OFCP collects, uses and discloses personal information related to this application only for the purposes of assessing, processing and administering this application and may exchange such information with the above-mentioned contact person, vendors, medical professionals and other agencies. I consent and (as applicable) confirm the user’s consent to this collection, use, disclosure and exchange of personal information. For additional information regarding the OFCP’s personal information protection privacy practices, please refer to our Privacy Policy on OFCP website.

Certification

I certify that the information provided in this application is true, correct and complete to the best of my knowledge and that the equipment has not been received. Approval of this application in this funding year does not guarantee approval in concurrent years.

By checking the ' I agree and give permission to process this application ' box below, as the applicant or applicant guardian, you are giving permission to OFCP staff to process your application accordingly and will indicate that you have read the ADFP guidelines and application.

I am the *

Applicant Parent or guardian

By agreeing to the above terms, as the applicant, I am giving permission to OFCP staff to process this application accordingly *

I agree and give permission to process this application

By agreeing to the above terms, as the applicants' parent / guardian, I am giving permission to OFCP staff to process this application accordingly *

I agree and give permission to process this application

Relationship to Applicant (if applicable):

I certify that the information provided in this application is true, correct and complete to the best of my knowledge *

Yes

I confirm that I have read and understand all of the ADFP Program criteria & guidelines *

Yes

Date *

yyyy mm dd

Supplemental ADFP Application Forms

ADP APPROVAL CONFIRMATION SHEET - Please have your prescribing Health Professional (Occupational or Physiotherapist) complete this sheet if the item you are requesting funding for has been approved by the Assistive Devices Program (ADP), Ministry of Health and Long-Term Care.

Attach documents to submit with your application here

Browse For Your Files

You can attach and upload any electronic documents to accompany your application here

Or drag and drop your attachments here:

Please ensure all information and supporting documentation are provided. If any information is missing or the application is incomplete, the applicant or primary contact person will be notified for completion and submission of missing information.

If we do not hear from the applicant within two weeks the application will no longer be active.

If you require additional information regarding this application or have any questions please contact the Ontario Federation for Cerebral Palsy

416-244-9686 ext: 221 or toll free 1-877-244-9686 ext: 221

Email: adfp@ofcp.ca

Please note: Attach documents to this online application BEFORE you click SUBMIT below.

The save button below allows you to save a partial filled out application, (you DO NOT have to login - connect with google or facebook, you can click 'Skip Create Account' ) and it will send you an email with your form and a link, and clicking that link would bring you back to your partialy filled out form, so you can continue to finish it, then submit it.