SRFN Wellness Incentive

Date

Name*

Email*

Home Phone

Cell Phone

Treaty Status Number*

Mailing Address*

City/Town*

Province*

Postal Code*

Minor Children/Dependant Information - Please include full name, status #, birthdate and relationship to applicant for each*

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