Equipment Funding Application Eligibility Check Are you a resident of British Columbia?* Yes No Sorry, you must be a resident of British Columbia to be eligible for this funding program. Date of Birth* You must be 19 years or older to be eligible. Sorry, you must be at least 19 years of age to be eligible for this funding program. Back Continue Is the equipment you are requesting for a temporary or permanent need?* Permanent Temporary Sorry, this funding program only supports equipment for permanent needs. Disability Type* Please select... Acquired Brain Injury ALS Amputation Cerebral Palsy Multiple Sclerosis Muscular Dystrophy Polio Spina Bifida Spinal Cord Injury Stroke Other Sorry, your disability type is not eligible for this funding program. Equipment Type* Please select... Back-up wheelchair Scooter Power wheelchair Manual wheelchair Custom orthotics Specialized wheelchair seating system Ramp Portable lift system Walker Other Sorry, the equipment type you selected is not eligible for this funding program. Personal Information Full Name* Date of Birth Email Address* Phone Number* Format: 123-456-7890 Street Address* City* Postal Code* Format: A1A 1A1 Province British Columbia Marital Status* Please select... Single Married Common-Law Separated Divorced Widowed Number of Dependents* Disability Description Disability Type Additional Disability Details* Date of Injury or Diagnosis* Requested Equipment Equipment Type Amount Requested ($)* 1st Quote NEW ($) 2nd Quote NEW ($) 1st Quote USED ($) 2nd Quote USED ($) Other Funding Sources Funding Source 1 Funding Source 1 Name Funding Source 1 Phone Funding Source 1 Committed ($) Funding Source 1 Requested ($) Funding Source 2 Funding Source 2 Name Funding Source 2 Phone Funding Source 2 Committed ($) Funding Source 2 Requested ($) Are you willing to contribute your own money towards this need?* Yes No If Yes: $ Amount* Do you have Medical Coverage?* Yes No Medical Coverage Provider* Amount provided by Medical Coverage ($)* Outstanding Amount ($) If you are on Ministry of Social Development and have been denied for the equipment, have you appealed? Yes No Do you have a Medical Service Only (MSO) number with the Ministry of Social Development? Yes No If you are over the age of 65 and in need of equipment, have you applied to MSD for Life Threatening Needs? Yes No Explain Application to MSD for Life Threatening Needs* Do you have any work related goals?* Yes No Explain work related goals* Have you been on EI or medical EI in the past 3 years?* Yes No Employed?* Yes No Name of Employer* Attending school?* Yes No Number of courses* Have you received funding from BC Rehab in the past?* Yes No Amount allocated ($)* Date* Financial Disclosure - Income (Monthly) Please provide your monthly income from all sources: Salary/Wages ($) Self-Employment ($) Spouse Income ($) Old Age Security ($) Ministry of Social Development ($) Canada Pension Plan ($) Child Support ($) Social Security Disability Benefits ($) ICBC Settlement ($) ICBC Part 7 ($) Workers' Compensation ($) Work Pension ($) Other Income ($) Total Monthly Income ($) Financial Disclosure - Expenses (Monthly) Rent / Condo Fees ($) Property Taxes ($) Home Insurance ($) Gas / Maintenance / Repairs ($) Car Loan / Insurance ($) Canada Pension Plan ($) Child Care ($) Groceries / Food / Supplies ($) Medical / Dental / Medicare ($) Utilities: Cable / Satellite TV ($) Utilities: Heating / Electricity ($) Utilities: Telephone ($) Utilities: Other Expenses ($) Total Monthly Expenses ($) Financial Disclosure - Assets Do you own your own home?* Yes No Value of home ($)* Salary/Wages ($) Total Savings ($) RRSP/Stocks/Bonds ($) Other Assets ($) Total Assets ($) Financial Disclosure - Liabilities Mortgage ($) Credit Cards / Charge Accounts ($) Student Loans ($) RRSP/Stocks/Bonds ($) Other debt ($) Total Liabilities ($) Required Documents CRA Notification of Assessment* Please upload your latest CRA Notification of Assessment document (PDF or Word document only). Occupational Therapist Justification* Please upload your Occupational Therapist's justification document (PDF or Word document only). This site is protected by reCAPTCHA v3 and the Google Privacy Policy and Terms of Service apply. Submit Application
