Application For A Communication Device

This request is for a child enrolled in the following program(s):

Name of Community Service Worker (if applicable)

Phone Number of Community Service Worker:

Child/Youth Information

Parent/Guardian Information

Parent/Guardian Information

Applicant Information

Additional Clinician/Support Staff Information (SLP, OT, PT, Resource Teacher)

Responsibility: (Who will be responsible for maintaining/updating the device)




Current Access

Current Communication Skills – Receptive Language
*we acknowledge there are no prerequisites for AAC and this is for information only*

minutes duration

Current Communication Skills – Expressive Language

Please comment on child’s literacy skills (exposure to and interest in written language, sight words, etc.)

Please describe any previously introduced augmentative communication systems (ie. light tech) and their outcomes:

Describe the experience/exposure the child has had with computers or technology in general:

Implementation Plan:

iDevice Package Requested

Is this a replacement device?
If yes – do you have an iCloud backup to be restored on the new device?
*Please note all new devices will be automatically set up with our remote management system unless an iCloud backup is available*

Apps / Software:

Symbol Communication
Visual Schedule


Case Type
Colour of Case (for Ultimate or Seymac only*)
Is shipping required for outside of Winnipeg?

Funding Source (Please only check one if you know who the funder will be)

All applications must be submitted with a letter of support written by the child’s current speech-language pathologist. Additional letters from family and other clinicians are encouraged. Please click on Upload File to attach your letter(s):
Max file size 10MB.
Upload failed. Max size for files is 10 MB.
Please ensure your letter includes the following:

Get the signature pages by clicking here
There are three additional pages that require signatures from parents/legal guardians and the applicant/speech-language pathologist. Please click on Upload File to attach your additional pages once they have been signed.
Max file size 10MB.
Upload failed. Max size for files is 10 MB.
**Please ensure you have included your letter of support and the additional signature pages**

Thank you! Please contact us at if you've had any dificulty of have any questions.
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.