The Bedolfe Grant Application Page 1 of 7

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1 LET IN THE LIGHT PHYSICAL FITNESS FOR THOSE WITH MS SUPPORTING THE MS CAREGIVER This program has been made possible by a generous grant from The Bedolfe Foundation. APPLICATION FORM Please complete and return to: The Bedolfe Committee Multiple Sclerosis Society of Canada Brant County Chapter P.O. Box Brantford, ON N3T 1M2 Please read the Bedolfe Grant Program Guidelines and Criteria prior to completing and submitting your application. Copies are available on our website: or request a copy from our local office by calling (519) Section A Applicant Information: Name: Address: Postal Code: Phone: May we communicate with you by ? Yes No If yes please provide your address here: Are you a member of the MS Society, Brant County Chapter Yes No Are you the Caregiver? Yes No If you indicated Yes, please provide a brief description of your care-giving role: The Bedolfe Grant Application Page 1 of 7

2 Section B Self-Declaration This program provides services, activities or items that contribute to the well being of the person with MS through contributing to their emotional, spiritual, physical and/or social rejuvenation as well as providing funds to enable primary caregivers of people with MS to maintain their own health and well-being while providing assistance and support to someone with MS and thereby enhance their own quality of life. Please read and sign the declaration that follows: I, declare that I am an individual who has a (your name) diagnosis of MS. I further declare that I require (caregiver s name) to help care for me. For this reason I require financial assistance with the request identified in this application in order to meet my personal needs or the needs of my caregiver and the information provided in this application is accurate and true. Signed: Date: (your signature) Signed: Date: (caregiver signature) Section C Funding Request Please indicate the category of funding you are requesting: Let In the Light (max $500) will give applicants the opportunity to get a break from the routine of living daily with MS. It might mean tickets to movies, a concert or a play. It could also mean adding something extra (non-structural in nature) to their home and/or yard whether it be enhancing a garden, landscaping or maintenance for a yard, getting paint or wallpaper to enhance your home. You could purchase new drapes, bedspreads or an easy chair to provide comfort. There are many possibilities in this category. Physical Fitness for those with MS (max. $350) provides those living with MS access to yoga, tai chi, swimming or another fitness program in the community. Studies have shown that the benefits of exercise to people diagnosed with MS include: reduction in fatigue, spasticity and pain as well as improving muscle tone, strength and overall endurance. Chiropractic, naturopathic, osteopathic, physiotherapy, registered massage therapy or treatment from a podiatrist could also be included if these services are not already being covered by a current health service provider or insurance. Supporting the MS Caregiver (max $150) is designed to support an activity that a caregiver engages in to get a break from the rigours of care giving. It could be a weekly massage, a fitness club membership, go to a movie; bowling or whatever form of relaxation they feel may help them. Respite care is covered through our Client Services Program. The Bedolfe Grant Application Page 2 of 7

3 Provide a brief description of the specific service, activity and/or purchase for which you intend to use the funding: Describe how the above request will benefit you as the person with MS or your caregiver. In other words, how will it. Provide you with support for your personal needs Provide you with a break, time off or relief from your daily routine and/or responsibilities Contribute to your emotional, spiritual, physical and/or social rejuvenation helping you to have more balance in your life and/or the reserves and resources you need Identify the source from which you will obtain the service/activity/item(s) identified above: LET IN THE LIGHT: Amount of Funding Requested: $ (Note: Requests must not exceed funding limits outlined in the guidelines) FITNESS: Amount of Funding Requested: $ (Note: Requests must not exceed funding limits outlined in the guidelines) CAREGIVER: Amount of Funding Requested: $ (Note: Requests must not exceed funding limits outlined in the guidelines) Expected date of service completion (i.e. when do you plan to purchase and utilize the service, activity or item identified in the above request?) Requests will be made on a first come first served basis and will be on a continual basis until the funds for the year have been exhausted. The Bedolfe Grant Application Page 3 of 7

4 Section D Funding Administration: Upon receipt of your application The Bedolfe Committee will review your submission and qualified applicants will be advised accordingly. Upon submission of receipts or paid invoices related to the approved grant, payment will be processed within 30 days. Recipients have the option of direct deposit or cheque payments. If you would prefer direct deposit please indicate below: I am currently set up for direct deposit with the MS Society of Canada and authorize use of this information to process my grant payment. I have attached a completed Direct Deposit Authorization form. I would prefer payment of the approved grant in cheque format. Section D Acknowledgement of Terms & Conditions: Disclaimer: The Multiple Sclerosis Society of Canada is not liable for any difficulties with suitability, safety, workmanship and/or maintenance related to services or items purchased with funds provided through this application. Privacy: The Multiple Sclerosis Society of Canada protects clients privacy. The information collected is used to provide services to clients, information about programs and meetings, and to compile anonymous statistical or summarized information for program evaluation and reporting. We may also contact you to request your voluntary participation in a follow-up evaluation for this funding project. Your personal information is shared with authorized individuals and companies outside the MS Society of Canada on a need to know basis, in relation to this application, only if a Release of Information Form is signed by the client. Please note: A release of information form must be signed by all applicants requesting funding. If there is not a Release of Information form attached to your application form please contact the Brant County Chapter Office at A copy of our privacy policy may be obtained by calling or at I acknowledge the above Terms & Conditions as well as the Criteria and Guidelines of the Bedolfe Grant Program and commit that all information provided is true and complete. I accept that the decision of the MS Society of Canada, Brant County Chapter Board of Directors regarding my application will be binding and final. Applicant Signature: Date: The Bedolfe Grant Application Page 4 of 7

5 Addendum A Release of Information Authorization (mandatory) Release of Information Form: By completing this form you hereby consent to the collection, use and disclosure by the MS Society of Canada of the information that you provided in this Bedolfe Foundation application, as it relates to your application. I, hereby give permission to release (print name) pertinent personal information from the Multiple Sclerosis Society of Canada. I wish to place the following restrictions on the release of t his information: dated at: in the province of Ontario this day of, 20. (signature) (address) I, have witnessed (name of witness) (name of client) place/his/her mark or signature on this document. I am satisfied that he/she understands the contents herein. (signature of witness) The Bedolfe Grant Application Page 5 of 7

6 Addendum B Authorization for Direct Deposit (optional) Multiple Sclerosis Society Ontario Division Clients AUTHORIZATION FOR DIRECT DEPOSIT PLEASE PRINT ALL INFORMATION Client Name: Client Address: Authorization: I authorize direct deposit via electronic fund transfer for payments from the MS Society and have included a voided cheque for the account that payment should be remitted to. Authorized Signature: REMEMBER TO ATTACH A VOIDED CHEQUE TO THIS FORM PLEASE DO NOT FAX Information collected on this form shall only be used for the purpose of setting up direct deposit via electronic funds transfer for payments by the MS Society and shall be maintained in strict confidence. Any questions relating to information required on this form or the direct deposit process should be directed to the Office Administrator, Brant County Chapter at or brantcountymssociety@rogers.com The Bedolfe Grant Application Page 6 of 7