Medical Newsroom Announcements Events Job Postings Media Releases Medical Travel Assistance Program Intake Form Section 1This program is available to citizens registered with Metis Nation-Saskatchewan and their immediate family members. Please note, abuse of the program and/or staff harassment may result in refusal from the program.First Name* Middle initial Last Name* Are you a citizen or an immediate family member of a citizen from the Métis Nation–Saskatchewan?* Yes No Relation to citizen - I am…MyselfMotherFatherSisterBrotherChildMN–S Citizenship Number (or your immediate family member)* Sorry, you have to be a citizen or an immediate family member of a citizen from the Métis Nation–Saskatchewan to proceed. Apply for MN-S Citizenship Street* City* Postal Code* Phone* Email Address Emergency Contact Information Name: Emergency Contact Phone Number Relation to Family Member Section 2What will you be using the Medical Travel Assistance Program for? Primary care appointment (e.g., vision, dental, family doctor) Non-primary care appointment (e.g., referral, specialist, prenatal) For your medical travel, which will you be needing assistance for? Accommodations Gas/Parking Healthy Food Allowance Do you want MN–S to book your hotel? Yes No Destination City* Check-in date* MM slash DD slash YYYY Check-out date* MM slash DD slash YYYY Consent* I agree to the Hotel Liability PolicyI agree to abide by all hotel rules and regulations provided by the hotel set forth at the time of check in. I acknowledge that I may be liable for any incidental costs and damages I have caused or by any persons staying or visiting with me. Should any invoice following my stay be received by MN–S, I acknowledge that I may be responsible for the charges incurred including incidentals (telephone, food, beverage, TV rentals, etc.) and other charges or damages, with the potential of limitations or suspension from future MN–S Medical Travel Assistance Program support. I acknowledge that if I do not check in on the requested date without sufficient notice, I may also be responsible for the incurred no-show fee. MN–S must be notified with at least 48-hours’ notice of cancellation to avoid a no-show fee. By providing my consent, I acknowledge I will adhere to the responsibilities and requirements brought forward by MN–S Ministry of Health for hotel accommodations booked on my behalf.Section 3Do you have any additional medical conditions that the program administrator should be aware of? Yes No Please explain Physician Name Physician Phone Number Appointment Location Please attach documentation of your appointment with this form* Drop files here or Select files Max. file size: 30 MB. NOTE: To receive reimbursement, you will also need to submit Confirmation of Attendance from your doctor after your appointment.Section 4We use the following information to calculate fuel costs. Include information for the vehicle you will be using or that someone else uses to drive you to your appointments.What is the make of the vehicle?* What is the model of the vehicle?* What is the year of the vehicle?* Household Income*Please select your yearly household income before tax. Reimbursement will be prioritized for those citizens with high needs and low income Under $40,000 $40,000 - $80,000 $80,000 + How many dependents live with you in your home (e.g. children under the age of 18, sick, disabled or elderly requiring care)?** 0 1 2 3 4 5+ Please provide us with any additional information we may need to serve you better.Consent and Acknowledgment* I acknowledge and consent to the following statement.I understand that by submitting this intake form to the Métis Nation–Saskatchewan (“MN–S”) for enrollment into the Medical Travel Assistance Pilot Program (“the Pilot Program”), I am consenting to the collection and use of my personal information for the purposes of administering my application and participation in the Pilot Program. I understand that this information is necessary for the purposes of administering my application and participation in the Pilot Program. I understand that my consent to collection and use of my personal information is a condition to my acceptance into the Pilot Program. 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 Program. I authorize MN–S 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 Program 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.