Section 3: Financial Information

Section 4: Therapeutic Goals

Section 5: Additional Information

Section 6: Supporting Documents

• a) Revenue Quebec Notice of Assessments of BOTH parents
• b) Canada Revenue Notice of Assessments BOTH parents
• c) Photocopy of child’s Medicare card
• d) Photocopy of Insurance Policy






Section 7: Consent and Agreement

I hereby grant permission for the organization to verify the provided medical and financial information.
I declare that the information provided in this application is true and accurate to the best of my knowledge.




Section 8: Signature

19. Applicant’s Signature:



CONSENT TO OBTAIN MEDICAL INFORMATION of A CHILD

Parent/Guardian Name:
Child’s Full Name:
Child’s Date of Birth:
Healthcare Provider/Facility:


This authorization includes, but is not limited to, the release of information regarding the child’s medical history, diagnosis, treatment, and any other relevant medical information. The purpose of this consent is to allow the specified healthcare provider or facility to share information with:

Name of Recipient:


unless otherwise revoked in writing by the undersigned.

I understand that the information disclosed may be subject to privacy laws and regulations, and I release the healthcare provider or facility, as well as any individual or entity involved in the release, from any liability arising from the disclosure of the mentioned medical information.

I acknowledge that this consent is voluntary, and I have the right to refuse or revoke it at any time by providing written notice to the healthcare provider, facility, or CJ Riders Foundation. This consent is valid for 6 months from the date signed below.

Signature of Parent/Guardian:
Date:
Witness (if applicable):
Relationship to Child (if not the parent):