FSCD Online Application Form – Fill Out and Use This PDF

Application for Family Support for Children with Disabilities

To apply to the Family Support for Children with Disabilities (FSCD) program you must be the child’s guardian.

If you are applying for more than one child, please complete and submit a separate application for each child.

The personal information that you are being asked to provide is collected under the authority of the Family Support for Children with Disabilities Act and Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. Personal information is managed in accordance with the FOIP Act and is only disclosed if it is authorized or required by law. Your personal information will be used to determine eligibility and to provide services to your child and family. If you require assistance completing the form or have any questions about the collection or use of your personal information please contact your Regional FSCD office which can be reached toll free at 310-0000.

CHILD:

Last Name of Child

First

Initial

Other names (alias) child is known by

Gender

Date of Birth (yyyy/mm/dd)

M

F

Address

City/Town

Postal Code

Phone Number

Is your child a Canadian citizen or a permanent resident of Canada?

Yes

No

You will be asked to show a copy of your child’s Birth Certificate, Record of Live Birth, Permanent Resident or Citizenship Card, Passport, IMM 5292 Confirmation of Permanent Residency, or IMM 1000 Record of Landing when you meet with an FSCD worker (do not mail these documents).

GUARDIAN(S):

Last Name of Parent/Guardian

First

Other names (alias)

Relationship to child

Gender

Date of Birth (yyyy/mm/dd)

M

F

Address (if different from child’s)

City/Town

Postal Code

Daytime Phone Number

Last Name of Parent/Guardian

First

Other names (alias)

Relationship to child

Gender

Date of Birth (yyyy/mm/dd)

M

F

Address (if different from child’s)

City/Town

Postal Code

Daytime Phone Number

CHILD’S DISABILITY INFORMATION:

What is your child’s diagnosis or condition? (PLEASE ATTACH COPIES OF MEDICAL LETTERS)

Provide any other information you would like to add about your child's disability and how it impacts them in their day to day activities:

(PLEASE USE BACK OF PAGE IF YOU NEED MORE SPACE):

ADDITIONAL INFORMATION:

Have you and/ or your child been involved with the FSCD Program in the past?……………………………………………………..		Yes		No
Is your child First Nations or Métis?		Yes		No

An FSCD worker will contact you to discuss your application at the daytime phone number you have provided.

Name of Guardian		Guardian Signature		Date (yyyy/mm/dd)
Name of Guardian		Guardian Signature		Date (yyyy/mm/dd)
FSCD3597 (2010/11)