SECTION 1: CHILD'S INFORMATION
Legal Given Name:
Legal Family Name:
Child's Date of Birth (mm/dd/yyyy):
Child's Gender:
FemaleMaleUnspecified
Mailing Address (unit/apartment number, street name, P.O. Box, city, province/territory, postal code):
Is the child registered:
YesNoPending (registration submitted)MétisNon IndigenousInuit
Child's 10 Digit Registration #:
If child is NOT registered and parent(s) are registered, has a registration number, complete the information below:
Parent Name (First & Last):
10 Digit Treaty Number:
DOB (mm/dd/yyyy):
Does the child normally live on reserve:
YesNo
Is the family receiving support from one of the following:
NoChild and Family Services Agency (CFS)Provincial Ministry of Social Services
If yes, which Community:
SECTION 2: CONSENTING PARENT/GUARDIAN'S INFORMATION
ParentGuardian
Given Name:
Family Name:
Address, if different from above (unit/apartment number, street name, P.O. Box, city, province/territory, postal code):
Telephone #:
Email Address:
I declare the information to be true and accurate and that it does not contain a request for any benefit or service previously paid for by Department of Indigenous Services Canada or by any other clan or program.
Please identify if you are a:
Signature:
Date (mm/dd/yyyy):
SECTION 3: REQUEST SUBMITTED BY (IF OTHER THAN PARENT/GUARDIAN)
Name:
Organization and relationship to child:
Mailing Address (unit number, street name, P.O. Box, city, province/territory, postal code):
SECTION 4: REASON FOR REQUEST
State details of the child's needs (i.e. medical, health, social, educational) (attach a separate page if necessary):
Has an assessment, prescription or referral been completed by a health, social or educational professional?
Is it attached?
SECTION 5: DESCRIPTION OF YOUR REQUEST (PLEASE ATTACH A QUOTE FROM PROVIDER IF APPLICABLE)
Requested Product/Services (provide a brief description)
Frequency/Duration (if applicable)
Estimated Cost (if known)
$
Total Amount Requested
Provide any details relevant to the request (attach a separate page if necessary):
SECTION 6: REQUEST HISTORY
Has this request been submitted to any other program or government department?
If yes, provide the name of program or department, outcome of the request and attach a copy of the document (if available):
