COVID-19 - Medical Supplies Support

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This form is for individuals or families needing medical supplies during COVID-19. Products will be distributed through contact free delivery to those in need.

Please fill out the following information so we can ensure we are providing support in the best possible way.

Name: *

Phone Number:

Email:

Address: *

How do you identify? *

First Nations

Inuit

Métis

Non-Indigenous

Do you face any barriers to accessing medical products (being able to purchase products, able to go to a store)? If so, please explain. *

Number of adults in household: *

Number of children in household: *

Please let us know which medical products you are currently in need of: *

Over the counter Pain Medication

Sinus Medication

Bandaids

Polysporin

Other:

Required

Please let us know if there are any specific medical conditions you need support for:

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