I understand that by submitting this intake form to the Métis Nation-Saskatchewan (“MN-S”) for enrollment into the Dialysis Transportation Pilot Program (“Pilot Project”), I am consenting to the collection and use of my personal information for the purposes of administering my application and participation in the Pilot Project. I understand that this information is necessary for the purposes of administering my application and participation in this Pilot Project. I understand that my consent to collection and use of my personal information is a condition to my acceptance into the Pilot Project.

I hereby waive any and all claims against the MN-S, its employees, directors, officers and agents, relating to the personal information that I am authorizing the MN-S to collect and use in administering my application and enrollment to the Pilot Project.

I DO HEREBY authorize the Métis Nation-Saskatchewan to collection of my personal information provided in support of my application to enable the MN-S to assess my transportation needs and to enable MN-S to confirm my entitlement to participate in the Pilot Project and to administer my participation in the same. I make this solemn affirmation conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.