First Name and Initial(s)Last Name Social Insurance Number

X X X – X X X –

VERIFICATION OF ELIGIBILITY FORMFor Students with Permanent Disabilities

Canada - Newfoundland and Labrador Integrated Student Financial Assistance ProgramFor the Canada Student Grant for Students with Permanent Disabilities (CSG-PD)(version française disponible sur demande)Form must be completed and signed in INK.Ensure all required signatures and supporting documents are attached.Collection and Use of Information: This personal information is collected under the authority of the Canada Student Loans Act, Canada Student Financial Assistance Act, and the Student Financial Assistance Act (Newfoundland and Labrador) as amended from time to time and will be used to determine and verify eligibility under the federal and provincial student financial assistance programs. If you have any questions about the collection and use of this information, contact the Director, Student Financial Services Division, Department of Advanced Education, Skills and Labour, Govern-ment of Newfoundland and Labrador, P.O. Box 8700, St. John's, NL, A1B 4J6 or (709) 729-5849.

STUDENT CONSENTConsent for the Collection and Disclosure of Personal Information

Your personal information is protected by the Access to Information and Protection of Privacy Act (Newfoundland and Labrador). I understand that, to determine and verify my eligibility for student financial assistance and related programs, to administer and enforce the Canada - Newfoundland and Labrador Integrated Student Financial Assistance Program, Student Financial Services Division may need to obtain my personal information. I consent to Student Financial Services Division collecting my personal information from the qualified medical assessor and/or educational assessor who completes the Verification of Eligibility Form, and to Student Financial Services Division providing personal information as may be necessary to obtain the information Student Financial Services Division requires or as may be necessary to administer and enforce the Integrated Student Financial Assistance Program. I also consent to these persons and entities disclosing my personal information to Student Financial Services Division for these purposes.

To be eligible, you must have a permanent disability which is defined as a functional limitation: • caused by a physical or mental impairment; and• that restricts your ability to perform the daily activities necessary to participate in studies at a post-secondary level or the labour

force; and • that is expected to remain with you for your whole life.

STUDENTFor students with a Learning Disability only:• Complete only Section A: Student Consent below; and • Submit a copy of your Psycho-Educational Assessment (or a comprehensive educational assessment) completed within the last 5

years or at the age of 18 or older and confirms the diagnosis of a learning disability and list barriers as a result of the confirmed learning disability.

All other students:• Complete Section A - Consent Form below.• Have Sections B, C and D relating to your disability completed by the appropriate qualified medical/educational assessor. Any

limitation/barriers to your program of study or the labour market must be clearly identified.

MEDICAL/EDUCATIONAL ASSESSOR• This Verification of Eligibility Form will be used as one of the criteria to determine this student’s eligibility to receive the Canada

Student Grant for Students with Permanent Disabilities. Please ensure the diagnosis represents this student’s permanent disability and identify the functional limitations/barriers that restrict/impact the student’s ability to participate in an educational setting or the labour force.

• Please complete all parts of Section B, C and D of this form pertaining to the permanent disability diagnosis and return the form to the student.

Signature of Student Date

SECTION A (to be completed by Student)

If Yes: • complete Section A ONLY; and • submit a copy of your Psycho-Educational Assessment (completed within the last 5 years or the age of 18 or

older and confirms the diagnosis of a learning disability and list barriers)If No: • complete ALL remaining sections of this form

Are you applying as a student with a Learning Disability ONLY? Yes No

THE CANADA STUDENT GRANT FOR STUDENTS WITH PERMANENT DISABILITIES PROVIDES ELIGIBLE STUDENTS WITH $2,000 PER ACADEMIC YEAR.

SECTION B (To be completed by Medical/Educational Assessor)

Determining eligibility for Canada Student Grant for Students with Permanent Disabilities (CSG-PD)

To be eligibile for the CSG-PD, the applicant MUST satisfy the following criteria:

1. Does the applicant have a Permanent Disability? Yes - Proceed to # 2 No – STOP! The student is not eligible.

2. The applicant MUST also have functional limitations or barriers to ONE or BOTH of the following (complete all that apply): Post-Secondary Education

List the functional limitations/barriers that restrict/impact the student’s ability to participate in an educational setting.

Notes: The list of limitations/barriers indicated in this table may be used to determine eligibility for the Canada Student Grant for Services and Equipment for Students with Permanent Disabilities (CSG-PDSE). (See separate Application Form) If no limitations/barriers exist for participation in post-secondary education, the student is not eligible for the CSG-PDSE.

Permanent DisabilityA person with “a functional limitation caused by a physical or mental impairment that restricts the ability of a person to perform the daily activities necessary to participate in studies at a post-secondary level or the labour force and is expected to remain with the person for the person’s expected natural life.”Functional limitation or barrier may be interpreted as: “anything that prevents a person with a disability from participating in post-secondary education or the labour market because of his/her disability, including a physical barrier, an information or communications barrier, a technological barrier, a policy or a practice (obstacle)”.

1.2.3.4.5.

Labour Market

List the functional limitations/barriers that restrict/impact the student’s ability to participate in the labour market.

If more space is required, please attach a sheet to this completed form.

1.2.3.4.5.

SECTION C

SECTION D

Nature of Disability – Check at least one box and Complete Section D

Name of Assessor (please print)

City/Town Postal CodeProvince

Professional Designation/Accreditation Registration/Certificate #

Mailing Address Telephone Number

Signature Date

Certification of Medical/Educational AssessorI certify that the information provided on this form is accurate and the student listed experiences the disability-related educational/labour market barriers indicated.

Physical Disability / Mobility Impairment PrimaryDiagnosis

Visual Impairment PrimaryDiagnosis

Hearing Impairment PrimaryDiagnosis

Psychiatric/Psychological DisabilityPrimaryDiagnosis

Speech or Language Impairment PrimaryDiagnosis

Neurological Disability PrimaryDiagnosis

Other PrimaryDiagnosis

Medical Office Stamp

(To be completed by Medical/Educational Assessor)

(To be completed by Medical/Educational Assessor)

IMPORTANT NOTE:You may also be eligible for additional funding through the Canada Student Grant for Services and Equipment for Persons with Permanent Disabilities, and the Grant for High Need Students with Permanent Disabilities (if required), to help pay for education-related services and equipment associated with your disability. You will be considered for these grants by completing a separate application - Application for Grants for Services and Equipment for Students with Permanent Disabilities.

AS A STUDENT WITH A PERMANENT DISABILITY: • You may have extra time to complete your program with the help of student

financial assistance funding. • You may qualify as a full-time student with a smaller, more manageable course

load. Students with a permanent disability are considered full-time if they are taking 40% or more of a full course load.

• You may qualify for extra funding that is specifically designed to help you pay for exceptional expenses related to your disability, such as transportation, specialized equipment, specialized textbooks, learning support services, and more.

For more information, please visit our website at www.gov.nl.ca/studentaid.

If you are applying for the Canada Student Grant for Services and Equipment for Persons with Permanent Disabilities (CSG-PDSE) and the Grant for High Need Students with Permanent Disabilities (if required):

• Complete the Application for Grants for Services and Equipment for Student With Permanent Disabilities; and

• you are encouraged to include a copy of your completed Verification of Eligibility Form (and Psycho-Educational Assessment, if applicable) to assist the official at your educational institution in completing the application.

Remember to complete your ONLINE APPLICATION

www.gov.nl.ca/studentaid

Please email to studentaidmailbox@gov.nl.ca, fax to 709-729-2298 or mail to Student Financial Services Division, Department of Advanced Education, Skills and Labour, P.O. Box 8700, St. John’s, NL A1B 4J6