Client Application Form

If you have any questions please call the office 250.861.5465
  • NA if not applicable
  • NA if not applicable
    Add a new row
  • NA if not applicable
    Add a new row
  • I, _____________________________ (applicant printed name) approve the release of my personal information as shown above with the understanding that this information is required to participate in the Hands in Service program or receive Hands in Service assistance and will only be provided to Hands in Service staff, volunteers or relevant health care providers as part of the Hands in Service program to ensure appropriate service delivery.
  • Please type your first & last name with today's date as an electronic signature.