Autism Direct Funding Application

Do you agree to submit this form electronically over the Internet? Do you agree to submit this form electronically over the Internet? Yes, I agree to sending this information over the Internet and acknowledge any security risks this may pose.

Child's First Name

Child's Last Name

Date of Birth

Age

Diagnosis

Diagnosis Made By

Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Email Address

Address

City

Postal Code

Is there more than one child/sibling in the home with an Autism Spectrum Disorder diagnosis? Is there more than one child/sibling in the home with an Autism Spectrum Disorder diagnosis? Yes No

Are you receiving Special Services at Home funding (SSAH)? Are you receiving Special Services at Home funding (SSAH)? Yes No

You indicated that you are receiving SSAH funding. Please enter the amount below (check your SSAH approval letter or contact your coordinator at Extend-a-Family Waterloo Region) You indicated that you are receiving SSAH funding. Please enter the amount below (check your SSAH approval letter or contact your coordinator at Extend-a-Family Waterloo Region) You indicated that you are receiving SSAH funding. Please enter the amount below (check your SSAH approval letter or contact your coordinator at Extend-a-Family Waterloo Region)

Yearly allocation of SSAH Funding? ($0.00)

Are you planning to use ADF for camp fees? (Please note that funding can only be used for camps starting April 1, 2025 until March 31, 2026) Are you planning to use ADF for camp fees? (Please note that funding can only be used for camps starting April 1, 2025 until March 31, 2026) Yes No

Name of Camp #1

Cost of Camp #1 per week

Address of Camp #1 (Include: STREET, CITY, POSTAL)

Select start date

Select end date

Do you want to add another camp? Do you want to add another camp? Yes

Name of Camp #2

Cost of Camp #2 per week

Address of Camp #2 (Include: STREET, CITY, POSTAL)

Select start date

Select end date

Do you want to add another camp? Do you want to add another camp? Yes

Name of Camp #3

Cost of Camp #3 per week

Address of Camp #3 (Include: STREET, CITY, POSTAL)

Select start date

Select end date

Are you planning to use ADF for Respite or for 1:1 Support Worker? (Please note that funding can only be used for respite starting April 1, 2025 until March 31, 2026) Are you planning to use ADF for Respite or for 1:1 Support Worker? (Please note that funding can only be used for respite starting April 1, 2025 until March 31, 2026) Yes No

First name of Support Worker #1

Last name of Support Worker #1

Hours per month to be worked

Rate of pay

Will you be using your Extend-A-Family Waterloo Region SSAH/Direct Support Person (DSP) to provide this respite? Will you be using your Extend-A-Family Waterloo Region SSAH/Direct Support Person (DSP) to provide this respite? Yes No

Do you want to add another support worker? Do you want to add another support worker? Yes

First name of Support Worker #2

Last name of Support Worker #2

Hours per month to be worked

Rate of pay

Will you be using your Extend-A-Family Waterloo Region SSAH/Direct Support Person (DSP) to provide this respite? Will you be using your Extend-A-Family Waterloo Region SSAH/Direct Support Person (DSP) to provide this respite? Yes No

Do you want to add another support worker? Do you want to add another support worker? Yes

First name of Support Worker #3

Last name of Support Worker #3

Hours per month to be worked

Rate of pay

Will you be using your Extend-A-Family Waterloo Region SSAH/Direct Support Person (DSP) to provide this respite? Will you be using your Extend-A-Family Waterloo Region SSAH/Direct Support Person (DSP) to provide this respite? Yes No

Are you planning to use ADF for a recreation or skill development program? (Please note that funding can only be used for respite starting April 1, 2025 until March 31, 2026) Are you planning to use ADF for a recreation or skill development program? (Please note that funding can only be used for respite starting April 1, 2025 until March 31, 2026) Yes No

Name of recreation/skill development program #1

Cost of program #1

Select start date

Select end date

Do you want to add another program? Do you want to add another program? Yes

Name of recreation/skill development program #2

Cost of program #2

Select start date

Select end date

Do you want to add another program? Do you want to add another program? Yes

Name of recreation/skill development program #3

Cost of program #3

Select start date

Select end date

Total Funding Requested Total Funding Requested Total Funding Requested

Enter your total funding requested (max $500)