FINANCIAL REQUEST FOR CLSCs LAC-ST-LOUIS AND PIERREFONDS PROFESSIONALS ONLY
Important : to avoid delays due to need for clarification, please ensure that all required information outlined below is included in request.
Date
Day/Month/year
Identification of the person initiating the request
Name of health professional
Phone
Ext
Email
Name of program and directorate
Request details
Basic request
For ALL:
Give contextual information
For CAMPS:
Provide the name of the camp and the duration
For CHEQUES:
give the name of contact person
Reason for the request
Have you ever requested help from the foundation for this client?
Yes
No
If yes, please justify this new request
Amount requested
Since the Foundation is a last resort for funding, what other sources have been approached?
Results of the financial research
Reason of the refusal
Program Manager Name
In block letters
Signature
All requests
MUST
be signed by the program managers
PLEASE NOTE:
All requests must be forwarded to the Board of Directors
Email
:
Mail
: CLSC du Lac-Saint-Louis, 180, avenue Cartier, Pointe-Claire, Québec H9S 4S1
Invoices must be emailed or mailed to the same addresses.