Enhanced Support Funding - Specialized Equipment Application

From time to time, child care programmes may need to purchase specialized equipment to help support a child to actively participate in the child care programme.

This application is to be completed by the child care programme based on the needs of an individual child who is enrolled in their programme for special programme equipment due to a special need and/or disability.

For items to be considered for approval, they need to be recommended by a professional consultant (e.g., OT/PT/Speech/Doctor)

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Child Care Programme

Home Child Care

Child Care Programme

Name of Child Care Supervisor

Name of Provider

Date of Application

Child's First Name and Last Name

Child's Date of Birth

The parent(s)/guardian(s) have been informed of the recommended equipment in this application and have provided their informed consent for both the application and the integration of the specified equipment into the programme to support their child.

The programme has an ISP in place or is currently in the process of creating an ISP for this child

Attached is the recommendation from a professional consultant for items being requested.

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General Information

Please add the list of materials below:

Re-order	Name	Description	Cost of each Item ($)	Weight	Operations
	Name	Description	Cost of each Item ($)	Item weight

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Total funding requested for enhanced support materials/equipment: $0

Please provide details of the reason this request is being made

Fiscal Need - Please describe why the programme needs financial assistance for the Enhanced Support Staff or Specialized Equipment

I/We hereby apply for Enhanced Support Funding for additional staffing, and declare that the enclosed statements are true to the best of my/our knowledge.

I/We understand that the needs of the child and the child care programme, and the plans of the child care programme, must meet specific criteria to receive funding.

I/We understand that this application and consequent contract for funding is between the child care programme and the County of Wellington.

I/We understand that the equipment purchased will belong to the County of Wellington Enhanced Support System and will be returned to the County of Wellington once the child leaves the programme.

By signing this form electronically, you agree your electronic signature is the legal equivalent of your manual signature on this form.

Signature of Child Care Programme Supervisor

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Signature of Home Child Care Provider

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Date

Privacy Notice

Personal information (PI) is collected under the authority of the Municipal Act, 2001. All personal information created, held or collected by the County of Wellington is protected in accordance with Municipal Freedom of Information and Protection of Privacy Act, 1990 (MFIPPA). For questions related to this collection of personal information, contact the Manager of Privacy and Information, County of Wellington, Office of the CAO, T 519.837.2600 x2528.