Hospital Comforts Application Form

Support Our Troops Hospital Comforts Application Form

All fields marked with an asterisk (*) are required. The French form can be accessed via the switch above.
- Personal information is collected by the Canadian Forces Morale and Welfare Services (CFMWS), under the authority of the National Defense Act, via a web-based application hosted by Jotform, a third-party company registered in Vancouver, British-Columbia.
  
  Personal information will be used to administer the Support Our Troops programs and to provide financial assistance. Your application is voluntary, however, if you choose not to provide your personal information, we may be unable to process your application and/or provide assistance. Personal information may also be used for marketing, program monitoring, evaluation, or reporting purposes, with the data being anonymized and aggregated whenever possible.
  
  Personal information is protected, and is only used and disclosed by CFMWS in accordance with the Privacy Act, as described in personal information bank CFMWS PPE 802 - Financial Assistance - Support Our Troops (SOT) Funds. Under the Act, individuals have rights of access to and correction of their personal information, and the right to file a complaint to the Privacy Commissioner of Canada regarding the institution’s handling of personal information.
  
  If you require clarification about this statement, contact the CFMWS privacy coordinator at ATIP.AIPRP@cfmws.com. For more information on the Privacy Act, consult the Office of the Privacy Commissioner of Canada. For the Jotform’s Privacy Policy, please visit their website at: Jotform Privacy Policy
- Section 1: Applicant's Information
  
  Hospitalized Individual
- Name*
  
  First NameLast Name
- Service Number*
- Email*
  example@example.com
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Canadian Armed Forces (CAF) member's military element*
- Applicant's CAF community (closest Base or Wing)*
- Section 2: Hospitalization Details
- Name of Hospital *
- Hospitalization Admission Date*
  
  DayMonthYear
- Hospitalization Discharge Date*
  
  DayMonthYear
- Section 3: Claimed Expenses
- Amenities*
  Max $10/day for the first month Max $5/day for the second month
- Parking*
  Max $75/month If you were charged HST, please enter full amount for parking including HST
- Claim Total
- Section 4: Required documentation
  
  Required documents for application to be processed
- Required documents: Proof of Hospitalization (i.e., discharge record), and Parking Receipts. *
  
  Application cannot be processed without these documents
  Cancelof
- Approved grant will be deposited to your bank account. Please include: Void Cheque or Banking information*
  
  Cancelof
- Section 5: Applicant Signature
- Signature*
  
  Clear
- Date of signature*
  
  DayMonthYear
- Claimant solemnly declares that he or any members of his immediate family have not submitted any insurance claim nor received any form of compensation for any of the expenses listed above and submitted for consideration and reimbursement under the provision of support from the hospital comforts fund.
Should be Empty:

Support Our Troops Hospital Comforts Application Form

Section 1: Applicant's Information

Section 2: Hospitalization Details

Section 3: Claimed Expenses

Section 4: Required documentation

Section 5: Applicant Signature