Government of Ontario: Ministry of Health and Long-Term Care Homes for Special Care

Program Funding Request

If space is insufficient, attach additional sheet.

Local HSC (Homes for Special Care) office

Contact name

Telephone number

1. Is the program/activity new or a continuation of an existing program/activity
New, indicate proposed effective date
Continuation, indicate initial effective date
and attach evaluation(s)

2. Is there an existing local program operated by a non-profit group/agency or volunteers
which provides support services and activities being proposed by this program.
No/Non
Yes, please list and indicate reason(s) for not considering them.

3. Program provider, agency or individual to provide activity
Name
Telephone/
Address, number and street name
City/Town
Province
Postal code
Non-profit
Profit, provide or attach particulars/description of program provider. , provide or attach particulars/description of program provider.

4. Program Type
Educational
Program description
Vocational
Program description
Recreational
Program description
Social
Program description
Life Skills
Program description
Physical
Program description
Other
Program description

5. Where will program be provided
Community , specify location
Residencial home, specify
Other, specify

6. Duration of Program, must not exceed 1 year.
After 1 year a new funding request is required.

7. Staffing of Program, include staff-resident ratio.
Staffing of Program, include staff-resident ratio.

8. Program goals and objectives
Program goals and objectives

9. Outline of program activities/
Number of hours
Day
Week
Individual
Group
Number of residents per session/Nombre de pensionnaires par session

10. Have resident(s) been included in and consented to program plan.
Please elaborate.

11. Residents participating in program

Resident's Name
Residential home
License number

12. Evaluation plan for program, include plan for assessing whether resident's individual objectives are being achieved..

Is program still needed
Yes
No

Semi annual evaluation required.

13. Funding requirements, all funding requests should be sufficient to represent the total expected cost of this program/activity and show a breakdown of the per diem rate br>
If space is not sufficient, attach additional sheet.

Transportion Required/Moyen de transport requis
Y
N

Cost
Source

If known, provide information on the following:
1. Staff salaries/Salaires des employés
2. Cost of supplies/Coût des fournitures
3. Cost of premises (office space)/Coût des lieux (bureaux)
4 . Other costs/Autres coûts

Signature of Homes for Special Care field staff
Date, yyyy/mm/dd

3883–41 (01/08)