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Online: Children's mental health Respite Grant Application

  1. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  2. By electronically signing you acknowledge that you have spoken to your client and have a signed release on file prior to submitting the referral
  3. Grant Manager Signature________________________________________Date:________________
  4. Leave This Blank:

  5. This field is not part of the form submission.