Do you have clients in need of language support? Fill out this application to know if your program/organization could receive subsidy support to help with interpretation costs. ๐๐ญ๐ญ๐๐ฐ๐ ๐๐๐ง๐ ๐ฎ๐๐ ๐ ๐๐๐๐๐ฌ๐ฌ (๐๐๐) ๐๐ฉ๐ฉ๐ฅ๐ข๐๐๐ญ๐ข๐จ๐ง ๐๐จ๐ซ ๐๐ฎ๐๐ฌ๐ข๐๐ข๐ณ๐๐ ๐๐ง๐ญ๐๐ซ๐ฉ๐ซ๐๐ญ๐๐ญ๐ข๐จ๐ง ๐๐ฎ๐ฉ๐ฉ๐จ๐ซ๐ญ Date (YY/MM/DD) Name of Organization* Name of program/service that will receive subsidy support:* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraรงaoCyprusCzechiaCรดte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRรฉunionSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTรผrkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweร land Islands Country How did you hear about Ottawa Language Access (OLA) subsidy program?* Website Colleague Friend Other If you selected "Other", please specify below. Please note the following questions are specifically for the program for which you are seeking subsidy.Is the program managed by a not-for-profit?* Yes No Location(s) of Program:*What is the source of funding for the program? (please select from below)* Government funding Corporate funding Self-funded Other ( please specify) If you selected "Other", please specify below. What is the type of funding for the program? (please select from below)* Permanent Temporary One-time Sporadic Please indicate your annual budget for the program.* Less than 100,000 100,000-200,000 200,000-400,000 400,000-1 million 1 million-2 million more than 2 million Has your program allocated funding towards interpretation services?* No Yes, Less than 5% Yes, 5%-10% Yes, more than 10% Is your program community based?* Yes No Which area of service does your program specialize in? (select all that apply)* Primary care Secondary care Tertiary care What are the estimated number of appointments for non English/French speaking clients per month? 0-30 31-60 Over 61 If your program runs sessions/appointments for clients, on average how long do they run?* Less than 1 hour 1-2 hours More than 2 hours I hereby acknowledge all the information provided above is correct and complete to the best of my knowledge and I am willing to verify information if requested.Name First Last Email* Phone*Thank you for your application. Please allow 1-2 weeks for review. Please note that all submitted information will be kept confidential, and is being collected specifically to determine eligibility for the subsidy program. All submitted applications will be reviewed but please note that submission of this form does not guarantee subsidy support. If your application is successful for subsidy support, you will be directly contacted by an OLA representative. For more information or questions, please call 613-288-2OLA (2652) extension 2 or Email: ola@swchc.on.ca. Δ