Apply for Assistance

Philae Shriners Can Assist You

Eligibility: Children up to age 18 who reside in Nova Scotia or Prince Edward Island are eligible to apply for transportation assistance provided the following criteria are met:

The Child’s condition must fall within the Shrine mandate of Orthopedic, Burns, Spinal Cord Injury or Cleft Lip & Palate.
The child must be a patient of the IWK Grace Hospital for Children (Halifax), or the Nova Scotia Rehab Centre (Halifax)
The child’s family must reside in Nova Scotia or Prince Edward Island, and must be more than 50km away from the IWK or NS Rehab.

Apply for Transportation Funding Assistance

Please complete this form, and we will contact you for further information.

Last Name (Patient)

First Name (Patient)

Street Address

City

Province

Postal Code

Sex

Male Female

Date of Birth (Patient)

Last Name (Father)

First Name (Father)

Street Address (If different than patient)

City

Province

Postal Code

Telephone (home)

Telephone (mobile)

Last Name (Mother)

First Name (Mother)

Street Address (If different than patient)

City

Province

Postal Code

Telephone (home)

Telephone (mobile)

Diagnosis

Type of Assistance

Referred By:

Philae Shriner Non-Shriner

Name of Philae Shriner

Date of Application