Families

Integrated Adult Services (IAS) Pilot Project Application

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Integrated Adult Services (IAS) Pilot Project Application

Important

Please provide the information requested below and click the "Submit" button to apply for participation in the project.

Applicant Information

Is someone assisting you with completing this application? Yes No

Name of person completing form (if other than applicant) and relationship to applicant:

Applicant given name(s):

Applicant surname:

Applicant Address:

Applicant's medical diagnosis(es):

Applicant is at least 18 years of age: Yes No

Applicant has a complex disability: Yes No Unsure

Please describe the impact the applicant's disability has on their daily living:

Contact Information

Telephone:

Email address:

Preferred method for follow-up communication: Phone Email Other

Please specify:

Demographic Information

2. How do you identify? (Select all that apply) Woman Man Non-Binary Transgender Two-spirit Another gender identity Prefer not to respond

3. Do you identify as Indigenous? If yes, please specify which you identify with. (Select all that apply) First Nation Inuit Métis Unknown Prefer not to disclose

5. In what community do you reside? Churchill East St. Paul West St. Paul Winnipeg

Important

Authorization to collect information

The Manitoba government and the Winnipeg Regional Health Authority are authorized to collect your personal information and personal health information under clause 36(1)(b) of The Freedom of Information and Protection of Privacy Act ("FIPPA") and section 13(1) of The Personal Health Information Act ("PHIA") respectively, as the information is directly related to and necessary for determining eligibility for the IAS pilot project.

Your information is protected by the privacy provisions under FIPPA and PHIA. The Manitoba government and Winnipeg Regional Health Authority cannot use or disclose your personal or personal health information for any other purpose, unless you consent or the administrators of the IAS pilot project are authorized or required to do so under FIPPA or PHIA.

Consent

I acknowledge my checking the "I consent" checkbox is sufficient to allow for the disclosure of the information requested. Consent is limited to this application only and becomes effective on the date submitted. This consent expires six months from the effective date.

I consent

Applicant Full Name:

Consent is provided on behalf of applicant

Applicant is assisted by:

Full name of applicant's legal representative:

Date:

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