Equipment Application

Please note: Applications will reopen on February 1, 2021 with a NEW application form. Old forms will no longer be accepted.

Please be patient as we process current applications and CLICK HERE look at our Frequently Asked Question (FAQ) page to find additional information.

Easter Seals Alberta has knowledgeable and friendly staff ready to assist you with your application. Please fill out the forms below and submit them using the “Submit Completed Form” button, or mail them to us at 103, 811 Manning Road NE Calgary AB T2E 7L4. 

Application Forms

For Home Automation and Give a Kid a Lift, please fill out the Equipment application. For Equipment and Support Services, please fill out all three forms.

Please Note

  • Easter Seals Alberta provides equipment to children, youth, adults, seniors and families with any disability.
  • Easter Seals provides the following mobility equipment when all other funding source options have been exhausted: hospital beds, lift assist chairs, porch lifts, stair lifts, mobility scooters, power wheelchairs, portable ramps and ceiling tracks.
  • Applicants must include their household Income Tax Notice of Assessment from two years prior.
  • Wait times can vary as this program experiences a high level of demand.
  • Information provided is confidential and used only for the purpose it was intended.

Medical Report Form

Occupational Therapist Assessment Form

Equipment Application