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RIH Community Sponsorship Program - Application Form
The RIH Community Sponsorship Program is a nominee based program that allows people who may not be able to access complementary health care, due to financial limitations, to have access to the care and services at RIH. Individuals can apply themselves or nominate friends, family, or community members in need.
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Nominee's name:
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Nominee's date of birth:
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Nominee's phone number:
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Nominee's email address :
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Health / medical reason for nomination:
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If you are nominating someone else, please provide your name, phone number, email and relationship to the nominee:
What services are being requested:
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Required
Practitioner requested:
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What is the estimated time this nominee needs care:
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The RIH Community Sponsorship Program financial guidelines align with the current living wage values for Revelstoke. Please answer accordingly:
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Check all that apply to the nominee:
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Required
Why do you think the nominee is a good candidate for the RIH Community Sponsorship Program:
If the nominee's individual or family income exceeds the living wage value but they are experiencing financial or family difficulty, they may still qualify for full or partial subsidy (please explain): 
If there is anything else you would like to share with us in regards to this nomination, please do so here:
Thank you so much for you submission! We will review your application and get in touch with you soon.
If you have any questions or concerns please call the clinic at 250 837 6084 or email us at clinic@revelstokeintegrative.ca.
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