For a "Printable" PDF of the application form click HERE

Name of individual requiring assistance: ________________________
Name of parent or guardian*: __________________________________
*(Only required if applicant is under 18 years of age)
Date of Birth: ____________________ Phone #:_________________
Address: ________________________ City_____________________
Province: _______________________ Postal Code: ______________
Email: _________________________________
Citizenship: _____________________________

The following information is required for your application to be processed:
- A letter explaining family personal circumstances and reason for monetary assistance. This letter shall be in English and no longer than 2 pages double-spaced.
- An itemized expense sheet outlining expenses incurred or to be incurred including but not limited to:
• Devices to improve quality of life
• Travel and treatment expenses not covered through Saskatchewan Health or private insurance
- Doctor certification
- Proof of necessitation – copy of previous year Income Tax Return

The Orange Benevolent Society shall award grants dependant on applications received with proper documentation and amounts available.
****Emergent applications will be considered throughout the year.

Release of Information:

I agree that the Orange Benevolent Society of Saskatchewan may:
-Contact vendors, once funding has been approved for the equipment / service being requested in this application for the purpose of facilitating grant payments.
-Carry out inquiries for the purposes of confirming or clarifying the information submitted, processing the application or addressing the application.
-Contact me for the purpose of obtaining feedback on the service
- Disclose any/all information in this application to such parties for the purposes as set out above.

I instruct and authorize The Orange Benevolent Society of Saskatchewan, to provide and release information to ________________________-(vendor of your choice), once funding has been approved for the equipment/service being requested.

Waiver:

I will indemnify and save harmless the Orange Benevolent Society of Saskatchewan and its employees from and against any and all expenses related to all claims, demands, liabilities, losses, costs, damages, actions, suits or other proceedings of any nature or kind whomsoever sustained, brought or prosecuted in any manner whatsoever, including without limitation based upon, occasioned by or attributable to the negligent act or omissions or the willful or reckless misconduct of the vendor/contractor, in the fulfillment of utilizing the funds provided by The Orange Benevolent Society of Saskatchewan.
The Orange Benevolent Society of Saskatchewan acts as a third party funding agency and as such has no role in prescribing, recommending equipment, selecting a vendor/contractor and in the relationship between the parent and vendor. Payment form the Orange Benevolent Society of Saskatchewan is not an acknowledgement that the work or equipment was acceptable.
I understand that if I am selected as a recipient, I consent to the Orange Benevolent Society of Saskatchewan using photographs or film of myself for the purpose of promoting or publishing the work the Society. I agree to indemnify the Orange Benevolent Society of Saskatchewan for any claims made against it arising out of the use of such photographs or film.

Certification:

I certify that the information provided in this application is true, correct and complete to the best of my ability.

_____________________________ _______________________
Signature/Guardian Date

Mail to:
OBS
Box 160
Indian Head SK
S0G 2K0
306-695-3450