Herbert T Bailey Application Form – Registered Nurses Foundation of Ontario

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Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Insurance and Financial Information

Have your applied for benefits through WSIB?

Yes

Upload a copy of the WSIB decision document

Accepted file types: jpg, png, gif, pdf, docx, doc, Max. file size: 20 MB.

Have your received benefits from any other long-term disability program?

Yes

If yes, what is the source of these other benefits?

Currently what is your MAIN source of income (select only 1)

Employment

Private Disability Insurance

Publicly supported insurance ( eg ODSP, WSIB)

Personal savings

Family Support

Publicly funded income support program (eg EI, Welfare)

Other

If you are approved for a grant, please provide an email address that we can use to transfer funds. If you don't use on-line banking, please provide the address to which we should send a cheque.

Background Information

Provide your current or former CNO registration number

Upload your statement of need

Accepted file types: jpg, png, gif, pdf, docx, doc, Max. file size: 20 MB.

Job Title

Job title for the position held at the time of your illness or injury.

Employer

Employer at the time of your illness or injury.

Start date for the employment listed above

MM slash DD slash YYYY

End date for the employment listed above

MM slash DD slash YYYY

Have you been employed since your illness or injury?

Yes

Upload your resume

Accepted file types: jpg, png, gif, pdf, docx, doc, Max. file size: 20 MB.

Disability and Retraining Information

Summary of Limitations

Summarize the limitation(s) that prevent you from returning to the position you held before your illness or injury. (Details should be included in your Statement of Need)

Do you have documentation from a health care professional certifying your ability to work?

Yes

If yes, please upload a copy of the document

Accepted file types: jpg, png, gif, pdf, docx, doc, Max. file size: 20 MB.

Name of the course or program you are taking

Upload documentation confirming fees and or payment for the course described above

Drop files here or

Accepted file types: jpg, png, gif, pdf, docx, doc, Max. file size: 20 MB, Max. files: 3.

If you have completed the course, upload proof of successful completion.

Accepted file types: jpg, png, gif, pdf, docx, doc, Max. file size: 20 MB.

I confirm that all information submitted in this application is accurate.(Required)

Yes

Herbert T Baily Memorial Fund

Insurance and Financial Information

Background Information

Disability and Retraining Information