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.

Has your child been diagnosed with ASD from a medical professional? Has your child been diagnosed with ASD from a medical professional? Yes No

You indicated that your child has been diagnosed with ASD from a medical professional. Please provide the full name of the diagnosing doctor. You indicated that your child has been diagnosed with ASD from a medical professional. Please provide the full name of the diagnosing doctor. You indicated that your child has been diagnosed with ASD from a medical professional. Please provide the full name of the diagnosing doctor.

You indicated that your child has not been diagnosed with ASD from medical professional. We regret that you are ineligible for funding at this time. You may not submit an application. You indicated that your child has not been diagnosed with ASD from medical professional. We regret that you are ineligible for funding at this time. You may not submit an application. You indicated that your child has not been diagnosed with ASD from medical professional. We regret that you are ineligible for funding at this time. You may not submit an application.

Full name of diagnosing doctor

Child's First Name

Child's Last Name

Date of Birth

Age

Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Email Address

Address

#Unit (optional)

City

Postal Code

Province (you must reside in Ontario)

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 planning to use ADF for camp fees? (Please note that funding can only be used for camps starting April 1, 2026 until March 31, 2027) Are you planning to use ADF for camp fees? (Please note that funding can only be used for camps starting April 1, 2026 until March 31, 2027) 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, 2026 until March 31, 2027) 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, 2026 until March 31, 2027) 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, 2026 until March 31, 2027) 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, 2026 until March 31, 2027) Yes No

Name of activity #1 (e.g. swimming)

Who runs the activity #1 (e.g. YMCA)

Location of activity #1 (e.g. 1 Main St. - OR - Pride Stables)

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 activity #2 (e.g. swimming)

Who runs the activity #2 (e.g. YMCA)

Location of activity #2 (e.g. 1 Main St. - OR - Pride Stables)

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 activity #3 (e.g. swimming)

Who runs the activity #3 (e.g. YMCA)

Location of activity #3 (e.g. 1 Main St. - OR - Pride Stables)

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)