Financial Assistance Application Form

The Fondation des Gouverneurs de l’espoir provides financial assistance to Quebec families whose child is diagnosed with cancer or a life-threatening serious illness and who have experienced a loss of income following the diagnosis.

 

Eligibility Criteria

  • Parents and the sick child must be Canadian citizens or permanent residents* and reside in Quebec. *Proof of permanent residency is required.
  • The child must have been diagnosed with cancer or a life-threatening serious illness.
  • The child must be under 18 (0-17).
  • The child must currently be under the care of a physician (official letter required).
  • The family must have experienced a loss of income directly related to the child’s illness.
  • The parent must complete the application form and provide all requested documents.
  • All forms of financial assistance must be declared.

Process

  • For a family’s request to be evaluated, they must provide a letter from the treating physician confirming the diagnosis and upcoming treatments, as well as all documents related to their request. The rigour of our approach allows us to help families truly in need within our budgetary limits.
  • The amount of assistance varies and can reach $1000 per month for up to 18 months for serious illnesses or as long as the child is undergoing cancer treatment. The difference between pre-diagnosis and current income determines the amount of assistance granted.
  • We never provide cash: we provide financial assistance in the form of gift cards for groceries, gasoline, pharmacy, and everyday purchases. It’s up to the family to choose the allocation and destination of the cards.

Please note that the Foundation has limited financial resources, and requests can only be accepted within the limits of available budgets. Your request may be put on hold due to budget constraints.

Attention: The form takes a long time to fill; we have no choice but to ask you many questions. It is strongly recommended to fill it on a computer rather than a phone 

  • Take the time to review the questionnaire so you can gather the information and documents before starting to answer.
  • You can save your answers and resume later by clicking on the button at the bottom of the form.

If you have any questions or difficulty filling this form, please contact the Family Services Coordinator, Karine Guillemette, at karine@gouverneursdelespoir.org.

Identification

Please fill in all required fields and provide as much detail as possible in the comments sections.
If no one referred you, write NONE

Parent 1 Information

*Only parents who are Canadian citizens or permanent residents are eligible for our assistance program. Do not fill out this form if you do not meet this criterion.
*Only residents of Quebec are eligible for our assistance program. Do not fill out this form if you do not meet this criterion.

Sick Child

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.
Please provide a letter from the treating physician confirming the diagnosis and treatment received.
Please provide explanations about your particular situation and the challenges you are facing so that we can better assist you.

Siblings

Social media and fundraising campaigns

Please check all that apply
If you have a comment, question, or explanation, please use this space.

Your Financial Situation

We need to assess the impact of the illness on your income to determine the amount of financial assistance you are eligible for.

Impacts of the Illness on Income

If Parent 1 had no salary, business income, or self-employment income, etc., indicate 0.
Please check all that apply. You must provide proof for each declared income.
Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.
Please provide proof for each income checked above.
If Parent 1 currently has no salary, business income, or self-employment income, etc., indicate 0.
Please check all that apply. You must provide proof for each declared income.
Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.
Please provide proof for each income checked above.
If you do not receive any amount from LEUCAN, please enter 0.
If you do not receive any amount from the Marie-Eve Saulnier Foundation, please enter 0.
If you do not receive any amount from another organization or foundation, please enter 0.
Please enter the date when Parent 1 stopped working.
Please enter the date when Parent 1 is expected to return to work.
If necessary, please use this space to provide additional information with explanations.
Drag & Drop Files, Choose Files to Upload You can upload up to 8 files.
Please provide one or more high-quality photos of the sick child. The photos may be used for promotional purposes of our mission.
Use this space as needed.

Final Step

  • I confirm that the information provided in this form is true.
  • I agree to provide the documents requested as part of the initial assessment and subsequent reassessments that occur periodically.
  • I agree to provide, upon request, the most recent Notice of Assessment from the Canada Revenue Agency.
  • I authorize the Foundation to use the photos I have provided.
  • If my request is accepted, I agree to sign and return the gift card receipt confirmation document each month.
Save and Continue Later

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