Golden Memories Fundraiser Application Form Golden Memories Application Personal InformationApplicant's Full Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Proof of Address(Required)Max. file size: 64 MB. Proof of Address includes any document, such as utility or phone bill, credit card statement, etc.Phone(Required)Email(Required) Financial InformationMonthly Household Income (before deductions)(Required)Do you receive any financial assistance?(Required) Yes No Please specify your financial assistance:Do you have any savings or assets?(Required) Yes No Please specify your savings and/or assets:Please check to identify specific eligibility requirement met. Upload document(s)in the section below: Receipt of Ontario Works Receipt of Essential Health and Social Supports Receipt of Ontario Disability Support Pension (ODSP) Receipt of a Guaranteed Income Supplement (GIS) Current Notice of Assessment (NOA) Upload DocumantsMax. file size: 64 MB. Care NeedsPlease briefly describe the services you require (e.g., meal preparation, light housekeeping, companionship, personal care, etc.):How often do you require these services? Daily Weekly Monthly Other Additional InformationAre there any specific challenges you are currently facing that make it difficult for you to maintain your daily activities?How did you hear about the Golden Memories Program?Terms of Service Agreement I agree to the Terms of Service.Disclosure in connection with electronic communications and e-signatures Please note that by clicking continue and signing this document generated on www.idealcaregivers4u.com you agree that you have reviewed the following disclosure and consent to (i) transact business by electronic means; (ii) receive documents electronically; and (iii) use the Ideal Caregivers 4u Inc. e-signature system. You are not under an obligation to receive documents electronically or use the IdealCaregivers 4u Inc. e-signature system. You may request to receive hard copy paper documents instead and withdraw your consent at any time by the procedure below.The field is required. Withdrawing consent You may withdraw your consent to receive electronic documents from Ideal Caregivers4u Inc. at any time. To withdraw consent, you must notify the sending party that you wish to withdraw consent by emailing the sending party directly. Please note that after you withdraw consent, if you choose to proceed after such time and use the Ideal Caregivers 4u Inc. e-signature system, you are consenting to receive and sign documents electronically. You can withdraw consent after the time you consent to use the system by following the procedure outlined above. Scope of consent You agree to receive electronic documents and use the Ideal Caregivers 4u Inc. e-signature system with all related and identified documents provided during your relationship with the sending party. You may withdraw your consent by following the procedures described above. By clicking the Submit button, I agree to the terms of service. * By clicking SUBMIT you consent to receiving SMS messages * Messages and Data rates may apply. Message frequency will vary * Reply Help to get more assistance * Reply Stop to Opt-out of messaging Private Policy - No mobile information will be shared with third parties/affiliates formarketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.Signature of Applicant, Legal guardian, or Power of Attorney:(Required)Date Signed MM slash DD slash YYYY
