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Government of Ontario: Ministry of Training, Colleges and Universities

Government of Canada

2012-2013 Application for Bursary for Students with Disabilities and Canada Student Grant for Services and Equipment for Persons with Permanent Disabilities

How to Apply

We recommend that you work with your school’s Office for Students with Disabilities in order to complete this application form. If your school does not have an Office for Students with Disabilities, you may contact the Ministry of Training, Colleges and Universities for assistance. Contact information is provided below.

For information on eligibility, please visit the OSAP website at www.ontario.ca/osap.

What Documents to Provide

You must include the following documents with your application:

    • Proof of your disability (see details below).

    • Documentation to support the services and/or equipment you are requesting. The documentation may be provided by a physician, regulated health care professional, or qualified assessor at your school.

    • Quotes for the cost of the services and/or equipment you are requesting:

      ○ If you are requesting funding for equipment, such as computers, scanners, software, etc., you must provide quotes from two businesses that sell the type of equipment you are requesting. Quotes for computers must reflect the MINIMUM system requirements necessary to facilitate your disability.

      ○ If you are requesting funding for services, such as tutors, or note takers, you must provide one quote outlining the hourly cost of the service, the number of hours per week that you require the service and for how many weeks, the number of courses you are taking where these services are required, and the name and contact information for the individual/agency that will provide the service.

    • A copy of the receipt verifying payment if you are requesting reimbursement of a learning disability assessment.

Proof of Disability

Acceptable documentation includes:

    • Medical documentation from a physician or other regulated health care professional who is authorized to diagnose your disability, with the following exceptions:

      ○ Learning disability assessments must be from a registered psychologist or psychological associate.

      ○ Attention Deficit Disorder (ADD) or Attention Deficit/Hyperactivity Disorder (ADHD) must be diagnosed by a registered psychologist or psychological associate, a neuro-psychologist, or a physician with ADD/ADHD training.

    • To be considered eligible for the Canada Student Grant portion of this funding, your medical documentation must include sufficient detail to confirm that you have a permanent disability. Permanent disability is defined as a functional limitation:

      ○ caused by a physical or mental impairment;

      ○ that restricts your ability to perform the daily activities necessary to participate in studies at a postsecondary level or the labour force; and

      ○ that is expected to remain with you for your expected life.

Receipts:

Receipts for equipment (including software) must be provided no later than 30 days after funding is issued. Receipts for services must be provided no later than 30 days after your study period end date. If you do not provide receipts according to these deadlines you may be restricted from receiving further bursary funding until you provide receipts. All receipts must reflect purchase dates after bursary funding is approved by your financial aid office and prior to your study period end date (some exceptions apply).

Where to Submit your Application

Ontario public college or university

If you are attending an Ontario public college or university you must submit the completed application form and required documents to the financial aid office at your school.

Private postsecondary school in Ontario or postsecondary school outside of Ontario.

Please note these are approved for purposes of the Ontario Student Assistance Program (OSAP).

If you are attending an approved private postsecondary school in Ontario or postsecondary school outside of Ontario you are responsibile for submitting the completed application form and required documents to the ministry at the address below.

Student Financial Assistance Branch

Ministry of Training, Colleges and Universities

PO Box 4500, 189 Red River Road, 4th Floor

Thunder Bay, ON  P7B 6G9

Telephone: 1-877-OSAP-411 (toll free in North America) or (807) 343-7260 or 1-800-465-3958 (TDD)

Deadline date to Submit your Application

One-term program (12 to 20 weeks in duration):

The completed application and all required documents must be received by your financial aid office within the first 30 days of your study period.

Two and three-term program (21 to 52 weeks in duration):

The completed application and all required documents must be received by your financial aid office no later than 90 days before the end of your study period

Government of Ontario: Ministry of Training, Colleges and Universities

Government of Canada

2012-2013 Application for Bursary for Students with Disabilities and Canada Student Grant for Services and Equipment for Persons with Permanent Disabilities

Student Information (to be completed by student)

Social Insurance Number

Student number (if known)

Ontario Education Number

Postsecondary school you are attending

Indicate the type of Ontario Student Assistance

Program (OSAP) aid you have applied for in

your current study period:

OSAP for Full-Time Studies

Part-Time Canada Student Loan/Grant

Institution-funded Special Bursary

First name

Last name

Date of birth (Day/Month/Year)

Permanent Address:

Street number and name

Apartment

City, town, or post office

Province

Postal code

Area code and telephone number

Mailing address (if different from above):

Street number and name

Apartment

City, town, or post office

Province or State

Postal code or Zip code

Area code and telephone number

Study period start date (Day/Month/Year)

Study period end date (Day/Month/Year)

Disability-Related Services and Equipment

(to be completed by Office for Students with Disabilities in consultation with student)

1 Learning disability assessment.

$ (Round to nearest dollar) 2 Tutors, note takers, academic strategists, readers.

Specify:

$ (Round to nearest dollar) 3 Interpreters/captioning (oral and sign language).

Specify:

$ (Round to nearest dollar) 4 Computer systems and accessories.

Specify:

$ (Round to nearest dollar) 5 Assistive software.

Specify:

$ (Round to nearest dollar) 6 Assistive equipment (e.g., CCTVs, digital recorders, FM systems).

$ (Round to nearest dollar) 7 Alternative formats (e.g., Braille, large print).

Specify:

$ (Round to nearest dollar) 8 Specialized transportation.

Specify:

$ (Round to nearest dollar) 9 Replacement/ Insurance/ Repair costs

$ (Round to nearest dollar) 10 BSWD only items: medical/psychological assessments, counselling, therapy, lifeline services, splints, ergonomic chairs, orthopedic supports, repairs to wheel chairs/hearing aids.

Specify:

$ (Round to nearest dollar)

TOTAL COSTS: $

Approvals

Office for Students with Disabilites Approval

(at public Ontario college or university only)

I hereby confirm:

    • the status of the student’s disability: the status of the student’s disability: Permanent    the status of the student’s disability: Temporary

    • that satisfactory supporting documentation has been provided to prove that the student has a temporary or permanent disability, and that the student requires the services and/or equipment identified above to participate in postsecondary studies; and

    • that the costs of the services and/or equipment indicated above are accurate, and where required, cost estimate(s) have been provided.

Disabilites Office Coordinator/Counsellor

Signature

Date

Financial Aid Office Approval

(at public Ontario college or university only)

I hereby confirm that the above named student:

    • has at least $1.00 of financial need under OSAP for Full-time Studies, Part-time Canada Student Loan and Grant Program, or an Institution-funded Special Bursary;

    • has had his or her disability-related education costs reviewed and approved by the Office for Students with Disabilities; and

    • is enrolled and registered at this postsecondary school for the current study period.

Financial Aid Administrator

Signature

Date

Financial Aid Office Approval

(for private postsecondary schools or postsecondary schools outside of Ontario)

I hereby confirm that the above named student:

    • is enrolled and registered at this postsecondary school for the current study period, and the study period start date and end date identified above are correct.

Financial Aid Administrator

Signature

Date

Government of Ontario: Ministry of Training, Colleges and Universities

Government of Canada

2012-2013 Application for Bursary for Students with Disabilities and Canada Student Grant for Services and Equipment for Persons with Permanent Disabilities

Student’s Consent, Declarations and Signatures

Notice of Collection and Use of Personal Information

Your personal information, including your Social Insurance Number (SIN), provided on this application form and in all other communications related to this application and any award of a Bursary for Students with Disabilities (BSWD) and/or Canada Student Grant for Services and Equipment for Persons with Permanent Disabilities (CSG-PDSE), including previous applications and awards of OSAP assistance will be used by the Ministry of Training, Colleges and Universities (the ministry) to administer and finance the BSWD/CSG-PDSE program and by Human Resources and Skills Development Canada (HRSDC) to finance the CSG-PDSE program. In addition, your SIN will be used as a general identifier in administering the BSWD/CSG-PDSE. The ministry and HRSDC may use contractors, auditors or other authorized third party administrators for any of these activities. Under agreement with the ministry, your postsecondary school and, where authorized by the ministry, its agents who administer OSAP and its auditors use your personal information to administer the BSWD/CSG-PDSE.

Administration includes: determining your eligibility for a BSWD and/or CSG-PDSE; verifying your application; verifying any award of a BSWD and/or CSG-PDSE; maintaining and auditing your file; assessing and collecting overawards; enforcing the legislation set out below and your agreements with the ministry, and monitoring and auditing your postsecondary school or its authorized agents to ensure that they are administering the BSWD/CSG-PDSE appropriately. In addition, administration by the ministry and HRSDC includes: public reporting on the administration and financing of student assistance programs; planning, delivering, evaluating and monitoring the BSWD/CSG-PDSE for quality and improvements in both content and delivery; conducting risk management, error management, audit and quality assessment activities; conducting inspections or investigations; and conducting policy analysis, evaluation, and research related to all aspects of the BSWD/CSG-PDSE, including contacting you to participate in surveys. Financing includes: planning, arranging or providing funding of the BSWD/CSG-PDSE.

The ministry administers the BSWD under the authority of s. 5 of the Ministry of Training, Colleges and Universities Act, R.S.O. 1990, c. M.19, as amended and s. 10.1 of the Financial Administration Act, R.S.O. 1990, c. F. 12, as amended, and the CSG-PDSE under the authority of the Canada Student Financial Assistance Act, S.C. 1994, c. 28, as amended, and the Canada Student Financial Assistance Regulations, SOR 95-329, as amended. If you have any questions about the collection or use of this information, contact the Director, Student Financial Assistance Branch, Ministry of Training, Colleges and Universities, PO Box 4500, 189 Red River Road, 4th Floor, Thunder Bay, ON  P7B 6G9, 1-877-OSAP-411.

Applicant's Consent to the Indirect Collection, Use and Disclosure of Personal Information (REQUIRED)

    • I agree that until I provide receipts and/or refunds for the BSWD/CSG-PDSE funding I receive and until any BSWD and/or CSG-PDSE overpayments are assessed and repaid, the ministry can, without limitation, collect and exchange personal information about me that is relevant to the administration and financing of BSWD/CSG-PDSE with my postsecondary school and its authorized financial administration administrators and auditors; the ministry's contractors, auditors or other authorized third party administrators; collection agencies operated or retained by the federal or provincial government, and consumer reporting agencies.

    • I understand that I can withdraw any consent I have given in this section by writing to the Director, Student Financial Assistance Branch at the address above at any time before I accept a BSWD and/or CSG-PDSE award. I understand that if I withdraw my consent it will affect my eligibility for and the amount of BSWD and/or CSG-PDSE assistance.

Applicant’s Declaration

    • I require this assistance for the cost of the disability-related services and/or equipment identified above, and I will not receive financial assistance from any other source to cover these costs.

    • I have given complete and true information on this application form.

    • I will keep a copy of my application and all required supporting documentation in the event that I am required to produce this information for audit, verification, inspection, or investigation purposes.

    • I agree that I will provide receipts for equipment (including software) no later than 30 days after being issued BSWD/CSG-PDSE funds, and I agree that I will provide receipts for services no later than 30 days after the end of my study period. These receipts will be submitted to my school’s Financial Aid Office or to the Ministry, as instructed in the “Where To Submit Your Application” section of this application form, and will show that BSWD/CSG-PDSE funds were spent for their approved purposes. If I do not submit these receipts I will repay by money order or certified cheque made payable to the Minister of Finance, any BSWD/CSG-PDSE funding that I have not used by the end of the study period for which I am requesting funding.

    • I understand that the funding I receive under the BSWD and/or CSG-PDSE must be used for the equipment or service identified on this application and may not be substituted for any other equipment or service.

    • I understand that I may be required to repay all or part of this assistance if the information I provide in connection with this application is found to be inaccurate for any reason or if any information I provide changes, including my study period and/or my course load.

    • I understand that information I provide in connection with this application will be verified and audited and the Ministry may also conduct inspections and investigations.

    • I understand that any change to the information I provide and any change resulting from verification and audit may affect my eligibility for and the amount of my BSWD and/or CSG-PDSE and that I may be required to repay all or a part of the BSWD and/or CSG-PDSE award.

    • I understand that if I fail to provide complete and true information; fail to promptly notify my financial aid office or the ministry in writing of changes to any information I have provided, including my disability and the services and equipment I need, my address and/or financial, academic, family, and/or study period status; or fail to fulfil any obligations respecting the repayment of any over awards the ministry may restrict me from receiving BSWD and/or CSG-PDSE or other OSAP assistance in the future, and may take legal action and may require me to repay any assistance that I received.

I have read and understood this section, including the notice of collection, use and disclosure of my personal information and my signature attests to my consent to the indirect collection, use and disclosure of my personal information.

Signature of Applicant:

Date

Institution Use Only (for publicly-funded colleges and universities in Ontario only):

Institution Use Only

Institution Code

Academic Year: From Academic Year: To

Course Load %

OSAP = 1

ISB = 2

Total Cheque Amount

Cheque Date * (Day/Month/Year)

Institution Use Only Cheque #1 Date (Day/Month/Year)

Amount Institution Use Only Cheque #2 Date (Day/Month/Year)

Amount Institution Use Only Cheque #3 Date (Day/Month/Year)

Amount

Ministry Use Only:

Ministry Use Only: Ministry Use Only: Satisfactory supporting documentation has been

provided as proof that the student has a temporary

or permanent disability:

Yes    No

Ministry Use Only: Status of student’s disability:

Permanent    Temporary

Ministry Use Only: Documentation has been provided to support the

need for services and/or equipment identified above:

Yes    No

Ministry Use Only: Student has at least $1.00 of financial need under

OSAP for Full-time studies, Part-time Canada

Student Loan/Grant Program, or an Institution-funded

Special Bursary:

Yes    No

Ministry Use Only: Where required, cost estimate(s) have been

provided:

Yes    No

Name of Ministry Staff

Signature

Date

Institution Code

Academic Year: From Academic Year: To

Course Load %

OSAP = 1

ISB = 2

PTCSL=3

Total Cheque Amount

Cheque Date (Day/Month/Year)

Ministry Use Only: Cheque #1 Date (Day/Month/Year)

Amount Ministry Use Only: Cheque #2 Date (Day/Month/Year)

Amount Ministry Use Only: Cheque #3 Date (Day/Month/Year)

Amount

34-1327E (2011/06)      © Queen’s Printer for Ontario, 2011

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