financial aid application form completed and signed

FINANCIAL ASSISTANCE 2016
Name of participant:
Age of participant:
Milieu de vie du participant :
Program and sojourn: _________________________________________________________
Amount requested: _______________________________________________________________________
Persons responsibles
Parent
Guardian
Parent
Curator
Curator
Other :
Other :
Person 1
Person 2
Name : __________________________________
Adress : _________________________________
City :_____________________________________
Postal code :_______________________________
Telephone :________________________________
Email :__________________________________
Family status : (circle the corresponding number)
12345-
Guardian
Name : ____________________________________
Adress : _________________________________
City : _____________________________________
Postal code :_______________________________
Telephone :________________________________
Email :__________________________________
Family status : (circle the corresponding number)
Marié ou conjoint de fait
Célibataire
Monoparental
Séparé/Divorcé
Veuf
1- Marié ou conjoint de fait
2- Célibataire
3- Monoparental
4- Séparé/Divorcé
5- Veuf
Dependent children
Name
Date of birth
Age
Schooling
1
2
3
4
5
6
How many people on the autism spectrum are living at home ? ____
Réservé à l’Administration
Ordre d’entrée :
No membre :
Gross annual income (before taxes)
PERSON 1
Parent / Guardian / curator / autre
PERSON 2
Parent / Guardian / curator / autre
ANNUAL TOTAL
$
$
$
Organizations that grant you a financial support for the
summer respite
Organizations
Amount
CSSS (Centre de Santé et de Services sociaux)
$
CRDITED (Réadaptation en déficience intellectuelle et TED)
$
Social Clubs (specify) :
$
Fondations (specify) :
$
Others (specify) :
$
TOTAL
$
Other information
Name of social worker
: _______________________________________________
Name of the organization
: _______________________________________________
Telephone number
: _______________________________________________
Each year, Emergo receives donations and grants to facilitate access to its services. We redistribute these funds in
the form of partial or total financial assistance to low-income families who request it, depending on available funding
and the number of eligible families. Financial assistance is given priority to families with autistic person or with ASD
living at home.
In addition to the financial aid application form, you must send the notice of assessment issued in 2014
by Revenue Quebec or Revenue Canada for both parents