SRFN Wellness Incentive

Name*

Last Name*

Mailing Address*

City/Town*

Province*

Postal Code*

Email

Home Phone

Cell Phone

Treaty Status Number

Are you claiming for a child or dependent? Are you claiming for a child or dependent? Yes

Name #1

Last Name #1

Treaty Number #1

Date of Birth #1

Add more Add more Yes

Name #2

Last Name #2

Treaty Number #2

Date of Birth #2

Add more Add more Yes

Name #3

Last Name #3

Treaty Number #3

Date of Birth #3

Add more Add more Yes

Name #4

Last Name #4

Treaty Number #4

Date of Birth #4

Add more Add more Yes

Name #5

Last Name #5

Treaty Number #5

Date of Birth #5

Add more Add more Yes

Name #6

Last Name #6

Treaty Number #6

Date of Birth #6

Add more Add more Yes

Name #7

Last Name #7

Treaty Number #7

Date of Birth #7

Add more Add more Yes

Name #8

Last Name #8

Treaty Number #8

Date of Birth #8

Add more Add more Yes

Name #9

Last Name #9

Treaty Number #9

Date of Birth #9

I consent to the sharing of my information with SRFN and their Membership and Finance departments for use in processing my emergency financial subsidy payment and for updating my contact information which will be kept in my band membership file I consent to the sharing of my information with SRFN and their Membership and Finance departments for use in processing my emergency financial subsidy payment and for updating my contact information which will be kept in my band membership file Yes No

You consent to share the following within Swan River First Nation You consent to share the following within Swan River First Nation Yes No

Date