Assistive Technology Project Request Form

CanAssist at the University of Victoria is dedicated to developing technologies, programs and services for people with disabilities (www.canassist.ca). One of the goals of our assistive technology program is to increase the independence, health and well being of those with special needs. It is also our great pleasure to be able to assist in the development of a device or technology that will meet each clients unique circumstances.
Please complete this form. The CanAssist team will consider all requests submitted. However, we reserve the right to decline any project request at our sole discretion.

Client Information
(i.e. the user of the technology)

Name: Address: City: Country: Phone: Fax: Nature of Disability: Province/State: E-mail:

Request Date: Postal Code:

Alternate Phone: Age: Gender:

Requestor Information
(if the Requestor is NOT the Client for example, a Clients parent/guardian/therapist/teacher/etc) (Please fill out the fields where the information is not the same as above)

Name: Affiliated Organization/Title: Address: City: Country: Phone: Preferred method of contact?

Relationship to Client:

Province/State: E-mail: Alternate Phone: Email Phone

Postal Code: Fax: No preference Yes No

Have you made a project request to CanAssist before? How did you find out about CanAssist? Have you reviewed the CanAssist website? Yes

No

CanAssist, University of Victoria, E-Hut, PO Box 1700, STN CSC, Victoria, B.C., Canada, V8W 2Y2 Phone: (250) 721-7300, Fax: (250) 721-7299, E-mail: info@canassist.ca, Web: www.canassist.ca

Technology Request Information Have you looked for a commercial solution? Please explain: Yes No

Please use the space/box below to clearly describe your assistive technology request. You are welcome to attach or provide additional pages, documents, photos, etc.

Thank you for contacting us. We will review your request and get in touch with you shortly. Should you have any questions about this form please do not hesitate to directly contact the CanAssist Client Relations Coordinator: Tanya Switucka, 250-853-3874, switucka@uvic.ca
Please note that CanAssist wants to help as many people with special needs as possible. However, given our limited resources and the increasing demand for our assistive technology services, we are usually able to undertake only one project per individual or family each year though this depends on the complexity and scope of the project. In exceptional circumstances or as our resources allow, we will consider more than one request per family in a year. Please contact our Client Relations Coordinator to discuss your situation. Thank you for your understanding.

CanAssist, University of Victoria, E-Hut, PO Box 1700, STN CSC, Victoria, B.C., Canada, V8W 2Y2 Phone: (250) 721-7300, Fax: (250) 721-7299, E-mail: info@canassist.ca, Web: www.canassist.ca