School Supplies Supplementary Funding Application Form

School Supplies Supplementary Funding Application Form

Primary Care Provider:

Name

First Last

Email

Address of child(ren) main residence

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Cell

Other Parent or Caregiver Information:

Name

First Last

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Cell

Children Data

How many Children are you applying for?

Name of Child 1

Birthdate

CAFN Enrolled Citizen*

Grade in Sept

School Name and Location in Canada

Birthdate

CAFN Enrolled Citizen*

Grade in Sept

School Name and Location in Canada

Birthdate

CAFN Enrolled Citizen*

Grade in Sept

School Name and Location in Canada

Birthdate

CAFN Enrolled Citizen*

Grade in Sept

School Name and Location in Canada

Birthdate

CAFN Enrolled Citizen*

Grade in Sept

School Name and Location in Canada

Do all parents/caregivers agree to this request?

Yes

No

PLEASE NOTE* Checks are mailed from the finance department so please ensure the correct mailing address is on this form. If you do not receive your check within 2-4 weeks please contact your Education Support Worker.

*CAFN Enrolled Citizen – is eligible to be enrolled in accordance to the CAFN Final Agreement – Chapter 3; and Section 5.1 (a) and 5.1(b) of the CAFN Aghaalan Enrollment Act. Enrolled citizens are considered beneficiaries.

**Non-Enrolled Citizen – a CAFN citizen who is not entitled to be enrolled under the CAFN Final Agreement – Chapter 3; but they have Indian Status with CAFN. Non-enrolled citizens are considered non-beneficiaries.

Primary Care Provider Signature:

Date

For Office Use Only

Date Received

Check Run #:

Amount Approved:

Approved

Yes

No

Reason: