Thank you to CIBC Miracle Day and to Graham Isenegger and Neil Chappell of CIBC Wood Gundy for their recent donation making this winter program possible this year!

Our family funding application period is open until November 25th with a goal of getting funds out by December 1st.

What is respite/recreation program? This program provides funding to be used by parents for respite services for the family or recreation service for the child with autism. During Covid, we are allowing these funds to be used towards subscription services or computer equipment to allow for virtual social experiences.

 

    Applicant/Guardian(s)*:

    Telephone*:

    Mailing Address (Include unit/appt number)*:

    City*:

    Province*:

    Postal Code*:

    Your Email*: (required)

    As you may know, we are a volunteer society. Please list ways you can help the society (VSCA):

    First Child with autism diagnosis:

    Child's Birth Date (YYYY-MM-DD):

    Second Child with autism diagnosis:

    Child's Birth Date (YYYY-MM-DD):

    Third Child with autism diagnosis:

    Child's Birth Date (YYYY-MM-DD):

    You may enter any additional information you want us to know (ie for instance, additional ASD Child):

    You may attach proof of autism diagnosis here or email to respite@victoriaautism.com by deadline
    (file limit 4mb, you may need to lower camera/phone resolution):
    No need to include if it has been previously provided. Don't worry, if we can't find it, we will simply ask you by email.

    Second Attachment (receipt) (optional):

    Recreation or Respite Provider's Name to put on cheque:*

    Recreation or Respite Provider's Phone Number:*

    Recreation or Respite Provider's Email:

    Any other information you would like us to know?:*