Medical Travel Assistance Program - Intake Form

I 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 and Mental Health and Addictions for hotel accommodations booked on my behalf.

Consent and Acknowledgment

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