APPLICATION FOR

ASSISTANCE.

Community Key helps families* that are caring for a seriously-ill or critically-injured child in paying their mortgage or rent payments.

*At this time, funding can only be provided to families within Canada.

FAQ

Please review our eligibility criteria before submitting your funding application.

Review Eligibility

Full Name of Child

Child & Family Information

Gender of Child

How many people live in your household?

If there are other children in the home, please list their ages.

Please tell us more about your situation and why you're applying for assistance. Please describe how the diagnosis of your child has changed your daily lives, if you have any support (family, friends), employment changes, etc.

Child's Medical Information

What is the child's official diagnosis?

Tell us more about this diagnosis.

If yes, what was the reason for hospitalization?

Please provide the name of the hospital.

What was the most recent admission date?

What was the most recent release date?

What is the child's current condition?

What is the name of your assigned medical worker?

What is this medical worker's position/title?

Provide your medical worker's contact information (phone/email)

Please provide any additional hospitalization details.

Parent & Guardian Information

Parent/Guardian 1

Parent/Guardian 1 Full Name

Parent/Guardian 1 Email

Parent/Guardian 1 Cell Phone

Parent/Guardian 1 Home Address

Parent/Guardian 1 Employer

Parent/Guardian 1 Occupation

Parent/Guardian 1 Job Status

Parent/Guardian 1 Leave Start Date

Parent/Guardian 1 Number of Unpaid Days

Parent/Guardian 2

Parent/Guardian 2 Full Name

Parent/Guardian 2 Email

Parent/Guardian 2 Cell Phone

Parent/Guardian 2 Home Address (If different than 1)

Parent/Guardian 2 Occupation

Parent/Guardian 2 Employer

Parent/Guardian 2 Job Status

Parent/Guardian 2 Leave Start Date

Parent/Guardian 2 Number of Unpaid Days

Income Information

Parent/Guardian 1

Parent/Guardian 2

Parent/Guardian 1 Monthly employment income BEFORE diagnosis (before tax)

Parent/Guardian 2 Monthly employment income BEFORE diagnosis (before tax)

Parent/Guardian 1 Monthly employment income AFTER diagnosis (before tax)

Parent/Guardian 2 Monthly employment income AFTER diagnosis (before tax)

Parent/Guardian 1 Child or spousal support amount

Parent/Guardian 2 Child or spousal support amount

Parent/Guardian 1 Child tax benefit amount

Parent/Guardian 2 Child tax benefit amount

Parent/Guardian 1 Other income amount (EI, CPP, Pension, Rental income)

Parent/Guardian 2 Other income amount (EI, CPP, Pension, Rental income)

Mortgage & Rent Information

Monthly mortgage or rent payment

Mortgage balance (approximately)

Property value (approximately)

Payment date of month

Number of missed payments

Who is your mortgage lender/landlord?

What is your main bank?

Assets

Savings (total)

RRSP, stocks, and other investments (total)

Expenses and Loss of Income Due to Diagnosis

Parent/Guardian 1

Parent/Guardian 1 Loss of income to date

Parent/Guardian 2

Parent/Guardian 2 Loss of income to date

Parent/Guardian 1 Total travel costs (gas, parking, airfare, etc.)

Parent/Guardian 2 Total travel costs (gas, parking, airfare, etc.)

Parent/Guardian 1 Total medical costs (deductibles, out-of-pocket expenses etc.)

Parent/Guardian 2 Total medical costs (deductibles, out-of-pocket expenses etc.)

Parent/Guardian 1 Other total costs (meals, childcare, etc.)

Parent/Guardian 2 Other total costs (meals, childcare, etc.)

Other Details

If yes, when did you receive it?

Family/Child's Website (ex. Facebook, GoFundMe, etc.)

Agree to contact about sharing story online

Is there anything else you would like us to know?

Applicant Email

Your name

How did you hear about Community Key?

Official date of diagnosis

Monthly Payments

Please list any additional monthly payments and debt obligations (e.g. car payment, line of credit, student loans etc.)

Apply Online

Please visit us on a desktop/tablet for our online application. You can also access a PDF form through the button below.

Download Application