Start Here: Declaration

All parents or guardians need to sign and have witness sign as well.

Section 1: Transportation to Doctors/Hospital/Clinic

List all medical professionals and estimate how many times per month you are seeing them and how you are getting there.
See example below:

Section 2: Meal Costs

List all medical professionals above if you get food while attending appointments.
See example below:

Section 3: Extraordinary Babysitting / Childcare costs

If you use a babysitter for your other children while attending the medical appointments listed above, please list the associated costs.
See example below:

Section 4: Extra Clothing

List any additional clothing purchases that are directly related to the child’s disability. For reasons such as excessive wear, lost items, sensory issues, messy eaters, accidents, etc.
List all items and how many extras you purchase through the year.
See example below: 5 extra pairs of pants x $20 = $100
2 extra snowsuits x $50 = $100
List total of all clothing items under yearly costs.

Section 5: Other Clothing Costs

List all clothing alterations, bedding, mattress protectors etc.

Section 6: Diapers

List all clothing alterations, bedding, mattress protectors etc.
Calculate your yearly diaper expenses. If you are receiving Easter Seals, subtract what you receive from your total. If you are not receiving Easter Seals, put the full amount under your yearly costs.
To Apply to Easter Seals, see Link: www.easterseals.org. Click on Services tab.

Section 7: Laundry Costs and Cleaning Supplies

If your child is frequently changing their clothes and requires more than 3 loads of laundry each week consider the formula below: 2 extra loads x $5 = $10 x 52 weeks = $520 1 extra Laundry detergent (additional laundry) per month @ $17 x 12 = $204

Section 8: Shoes, Boots and Orthotics

If you a require more then 4 pairs of shoes and 1 pair of boots for your child, please list cost below.
If Orthotics are required, please include a copy of the prescription and receipt, for any amount not covered by insurance.

Section 9: Special Diet

If your child has been prescribed a special diet, requires supplements, or has severe allergies please include the additional food cost.
Example: Ensure $15 x 52 weeks = 780

Section 10: Special Learning and Development Equipment

List items that you purchase to support your child’s learning and list $300 under your yearly expenses.
You may consider the following examples:

• Playdoh
• Lego
• Arts and craft supplies
• Books
• Puzzles
• Computer
• iPad
• Apps

Section 11: Special Education and Nursery School

List any special education classes that have been purchased. Please provide receipts for these services. This may also include tutoring services.

Section 12: Camp Fees

List any camps your child has attended in the past year. Please provide receipts for these costs. If camp has not been attended due to lack of finances, you may want to write "if funding was available, I would like my child to attend camp"

Section 13: Social Program Expenditures

List any social or recreation programs your child attended and associated cost. If you have not registered but would like to in future, please consider using the following statement.
"if funding was available I would like to register my child for …"
Some examples of social / recreation programs include:

• Social skills
• Brownies
• Girl guides
• Soccer
• Swimming
• Parks and Recreation activities

Section 14: Parent Relief

You can claim $150 a month for respite/parent relief. Please list the name of your worker or program (afterschool or weekend respite). You can use a family member if they are not living in the same home as you.

Section 15: Drug Costs

List all cost related to your child’s health that is not covered by OHIP or other insurance you may have.
Some examples you can use are:

• Vitamins
• Iron
• Prescribed creams
• Melatonin
• Allergy medication

Section 16: Equipment for Hearing Impairment

Please list all cost associated with your child’s hearing impairment if applicable.
Such as: Hearing aid batteries, Special headphones

Section 17: Medical and Surgical Supplies

Please list all cost for supplies
Such as: Gloves, Tape, Tensor Wraps, Sterile gauze, Bandages

Section 18: Repairs to Special Equipment

Please list all costs you incur maintaining special equipment.
Some examples may be:

• Wheelchair
• Walker or braces
• Tablet/iPad used for communication

Section 19: Other Expenses

List all other expensive that have not been covered in the sections above.
Some examples to consider:

• Damage to household items including repairing/painting walls
• Patching up holes in the wall
• Broken appliances

Consent to disclose and verify personal information and consent to recover overpayments.

Please ensure two consents are completed and signed.

Please make copies of supporting documentation to be included with the application:

• Birth Certificate/ Passport/ Immigration status of child
• Copy of Child’s Health Card
• Void Cheque
• Diagnosis Information / Reports (School IEP)
• Most current notice of assessment for all household income earners
• Birth Certificate / Passport / Immigration status of Caregiver
• Most recent copy of the Canadian Child Benefit

We recommend making a copy of your application for your records.

Mail in the application to: 375 University Ave. 5th Floor, Toronto ON, M7A 1G1