Child's Name
Child's Gender Identification
Choose as many as required.
Military Family?
Do you wish to identify this child as an Indigenous Person?

Diagnosis

Child has been diagnosed with:
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Section 2 of 3

Parent / Guardian Name
Address
Email
Preferred Method of Contact
How do you want to receive your decision letter?
Preferred Language
Is this Parent / Guardian's address the same as above?
Child Lives at:

Section 3 of 3

Service Request

All Funding Being Received

ACSD (Assistance for Children with Severe Disabilities)
SSAH (Special Services at Home)
Ontario Autism Program
Recreational Funding (Health Star, Jump Start, etc.)
Other
Acknowledgement