Applications for Services Application for Services & Funding Assistance Application for Services & Funding Assistance Registration Username: Password: Save Progress Section 1: Child Information 1. Child’s Full Name: 2. Date of Birth: 3. Parent’s Full Name: 4. Parent’s Phone Number: Address: Telephone Number: Diagnosis/Condition: Select which program(s) you are applying for: Mind Mastery Program: Tutoring Funding Adventure Avenue Program: Summer Camps & Activities Bright Futures Program: Funding Scholarships Gifts of Joy Program: Holiday Food Baskets & Toys Section 2: Medical Information 7. Primary Medical doctor/Healthcare Provider: 8. Contact Number Information of Medical doctor/Healthcare Provider: 9. Address of of Medical doctor/Healthcare Provider: 10. Brief Description of the Child’s Medical Condition: Section 3: Financial Information 11. Household members: Name Occupation Employer Annual Income Children & Youth: List all children/youths, including the applicant, currently living in your home: Name Age Section 4: Therapeutic Goals 14. Describe the therapeutic goals for your child: Section 5: Additional Information 15. Any Other Information You Would Like to Share: Section 6: Supporting Documents Please attach the following documents: a) Revenue Quebec Notice of Assessments of BOTH parents b) Canada Revenue Notice of Assessments BOTH parents Upload Files 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 Form 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): Please enable JavaScript for this form to work.
