2019 One to One Summer Support Worker Reimbursement Fund

Child/Youth Information

First Name

Last Name

Birth Date

Gender

Male

Female

What is the Primary Diagnosis?

Parent Information

First Name

Last Name

Street Address

Street Address Line 2

City

Postal Code

Phone Number

Phone Number 2

Are you a member of Autism Ontario?

Yes

Chapter Name (If Known)

Worker Information (If Known)

Worker First Name

Worker Last Name

Worker Street

Worker Apartment Number

Worker City

Worker Phone

Documentation

I am attaching the following:

Proof of Diagnosis (clear, legible copy)

Diagnosis is already on file at Autism Ontario

This completed, signed application

Proof of Diagnosis

One file only.
64 MB limit.
Allowed types: jpg png tif odf pdf doc docx.

Terms of Service

I agree to the terms of service.

Application Process

Autism Ontario is now accepting applications for participation in the Summer Fund for a minimum of 500 randomly selected families.
Please complete your signed application and mail with copy of diagnosis. (Your application will be assigned a unique number and you will receive a letter acknowledging our receipt of your application.)
Autism Ontario will notify all applying families whether they were randomly selected to receive funds by June 7, 2019. If you are selected, you will receive further instructions that you must follow to submit eligible receipts by no later than September 13, 2019 before reimbursement is made. Once all required documentation has been received, reimbursement of up to $600 will occur within 30 business days.

Note

Autism Ontario will provide reimbursement to a maximum of $600 per child/youth for fees incurred by their parent/guardian who retains the services of a one-to-one support worker (worker must be 18 or older) between June 24 and August 30, 2019 for their child/youth with ASD (ages 17 and younger).
Cheques will not be issued in advance of Autism Ontario receiving all documents (proof of diagnosis, signed application and original receipt(s)).
Membership in Autism Ontario is not required to access the Fund, as per Canada Revenue Agency guidelines. However, the child/youth for whom the funds are intended must have a diagnosis of an Autism Spectrum Disorder.

Release of Liability

I understand that no information will be released without my authorization. I will indemnify and save harmless Autism Society Ontario (operating as Autism Ontario) and each of their officers, directors, employees, volunteers and agents from and against any and all claims, actions or demands, including, without limitation, reasonable legal and accounting fees, alleging or resulting from my use of the family funding. I am aware that Autism Ontario neither supports nor endorses any one camp or program.

I am also aware that Autism Ontario does not endorse or train any individual for the purpose of working one on one with my child. (Autism Ontario complies with the Personal Health Information Protection and Electronic Document Act (PIPEDA). All information gathered is stored in a confidential manner. To view Autism Ontario’s Privacy Policy, please visit www.autismontario.com.)

By signing I am acknowledging the release of liability above and I am certifying that the information provided in this application is true, correct and complete to the best of my ability.