Métis Capital Housing Corporation > Resident Services > Homes > Homes for Seniors

Nihgi Métis Seniors Lodge

Thank you for applying to the Nihgi Métis Seniors Lodge. Please complete the form and click Apply Now. If you have problems, please call us toll free at 1-877-458-8684. We will do our best to help you.

Please fill out the required fields below.
When done, click "Apply Now" at the bottom of this page.

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Applicant

First Name of applicant: Enter your first name here.	*
Middle Initial of applicant: Enter your middle initial here.
Last Name of applicant: Last Name of applicant	*
Email address: Enter your email address here. This must be correct in order for us can contact you.
Date of birth (month/day/year): Indicate your date of birth by selecting a month from the drop-down box, entering the day in the next box and entering a 4-digit year in the last box.	*
Heritage: Select the heritage that applies to you from the drop-down list on the right.	*
Address: Enter your address here, using more than one line if you wish.	*
City: Enter the city you currently reside in here.	*
Province: Select the province you currently reside in from the drop-down list on the right.	*
Phone, Primary Contact: Enter your telephone number here, including your area code, for primary contact.	*
Phone, Secondary Contact: Enter your telephone number here, including your area code, for secondary contact.
Applicant's marital status: Select the marital status that applies to you from the drop-down list on the right.	*
Social Insurance Number: Enter your social insurance number here (9 digits)	*
AHC Number: Enter your AHC number here.	*
Alberta Blue Cross Number: Enter your Alberta Blue Cross number here.	*
DATS Number: Enter your DATS number here.	*
Vehicle License Plate Number: Enter your vehicle license plate number, if applicable
Vehicle Type and Color: Enter your vehicle type and color, if applicable
Method of Banking: Specify the form of banking applicant will use	*

Emergency Contact: Name & Address of Reponsible Relative or Friend
Emergency Contact #1 Information
Emergency Contact #1 Name: Enter the name of the your emergency contact person here	*
Address: Enter the address of the your emergency contact person here	*
Relationship: Specify person's relationship to applicant	*
Phone Number: Enter the phone number (including area code) of the your emergency contact person here	*
Alternate Phone Number: Supply emergency contact alternate phone number
Fax Number: Supply emergency contact fax number

Emergency Contact #2 Information
Emergency Contact #2 Name: Enter the name of the your emergency contact person here	*
Address: Enter the address of the your emergency contact person here	*
Relationship: Specify person's relationship to applicant	*
Phone Number: Supply emergency contact phone number	*
Alternate Phone Number: Supply emergency contact alternate phone number
Fax Number: Supply emergency contact fax number

Applicant Medical Information

Family Physician Name: Enter the name of applicant's family physician	*
Physician's Address: Enter in the address of the applicant's family physician	*
Physician's Phone: Enter phone number (including area code) of physician	*
Physical Health: Specify applicant's current state of physical health	*	ExcellentGoodFairPoor
Emotional Health: Specify applicant's current state of emotional health	*	ExcellentGoodFairPoor
Time in Hospital, past year: Specify the number of times you have been to emergency or in hospital in the past year	*
Any Falls in Past Year? Indicate whether or not you have fallen in the past year	*	YesNo
If you have fallen, how many times? Specify how many times you have fallen if you answered "Yes"

Support Information

Family/Friend Support? Indicate if applicant has family and/or friend support	*	YesNo
Day Program Support? Indicate if day program support is required	*	YesNo
Mental Health Support? Indicate if mental health support is required	*	YesNo
Home Care Support? Indicate if home care support is required	*	YesNo
Other Support: Specify other forms of support, if desired

Activities of Daily Living

Language(s) you are fluent in: Indicate languages you are fluent in	*	English: French: Aboriginal: Other:
Language Comments: Enter in any comments regarding language you feel should be taken into consideration
Aids Used in Daily Living: Specify which aids you require in the course of daily living	*	None: Cane: Walker: Wheelchair: Oxygen:
		Incontinence: Dentuires: Eyeglasses: Hearing Aid:
Medical Administered By: Specify whether your administer your own medical care of if it is performed by home care	*	SelfHome Care
Outlook on Life / Attitude: Choose which attitude best fits your outlook on life	*	PositiveNegativeApathetic
Independent Attitude: Specify which best describes your attitude towards independence	*	StrongLowOther

All Information Contained In This Application Will Be Held In Strict Confidence

I understand and further agree to:

Submit income verification to ensure qualifications are met in accordance with Policy and Guidelines
Authorize Métis Urban Housing Corporation to conduct inquiries re the approval of my MUHC Application
Submit a Criminal Record Check. If you know you have a criminal record, please request a detailed report.
Sign a Lease Agreement (month to month)
Pet Policy - strictly enforced (discuss exceptions with MUHC Staff)

Hover over or click on questions for further explanation

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