Survivor Support Fund Application

1. Name of church/agency applying *

2. Name of contact person from the church/agency *

3. Church/agency website

4. Church/ agency mailing address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

5. Contact person’s phone number *

6. Contact person’s email address *

7. How did you hear about the Defend Dignity Survivor Support Fund? *Church/agency has applied before From another church/agency In an email from Defend Dignity Defend Dignity websiteDefend Dignity social mediaOther

Specify

Note: The following questions pertain to the applicants themselves.

8. Name of the person in need (the applicant): *

9. Applicant’s date of birth *

10. Where does the person in need currently reside? *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Country

11. Is this person an official Canadian citizen? *YesNo

11. a. If this person is not a Canadian citizen or has immigrated to Canada, what is their status in the country (e.g. on a visitor visa, work/study permit, refugee status, permanent resident, immigrant, etc.)?

12. Is this applicant of indigenous descent? *YesNo

12. a. If yes, does he/she have official Treaty status?

13. What is the applicant’s gender? *MaleFemaleOther

Specify *

16. If this individual has been trafficked for the purpose of sexual exploitation, were they trafficked:DomesticallyInternationally

17. Is the applicant on social assistance from the provincial government (i.e. Ontario Works, Alberta Works, etc.)? *YesNo

Specify

18. For what purpose is the person you are applying for in need of access to this fund? IMPORTANT: Please prioritize and list by number the items with dollar amounts for ALL needs that are submitted. As per our policy, any individual can only receive up to $2,000 per calendar year from the Survivor Support Fund. The needs CANNOT exceed $2,000. For example- 1. Credit Card Debt- $500 2. New Bed- $800 etc. *

19. Please describe why you feel the applicant would benefit from accessing this fund at this time *max 250 words0 / 250

20. Please include information on the length of the relationship between the applicant and the church/ agency. Describe how you have supported this individual. *max 250 words

21. Please describe what other attempts the person you are applying for has made to find funding for this specific need. i.e. Funding from other agencies, social assistance, scholarships, loans etc. *max 250 words

22. Please describe how you will oversee the applicant’s use of any received funds. *max 250 words

23. Please include any additional information you feel may be relevant to this application for funding.max 250 words0 / 250

Letter From Survivor *

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