BCAAFC-TELUS Mobility for Good Program Application

Phone Recipient Information

Basic information of the recipient of the phone and plan. Please note this information is confidential and will not be shared unless in an emergency.

Phone Recipient Name

First

Last

Recipient Age

Recipient's Identity (Select All That Apply):

Address Identity Address

Recipient's Pronouns

Recipient's Indigenous Community

Recipient's Accommodation Type:

Recipient's Email (if available)

Recipient's Address (if available)

Does the Recipient Live on Reserve?

Yes
No
Sometimes/Unsure

How Urgent is this Request?

Low
Medium
High

Support Person Information

For the purpose of this program, a support person is someone employed at a BC Friendship Centre or other supporting organization who understands the community member’s context from an environmental and social situation. They can vouch that the a phone will act as a useful resource for the community member.

Please Select the Organization the Support Person is Employed At:

If Other, Please Provide the Organization Name:

Primary Support Person's Name:

First

Last

Primary Support Person's Email:

Organization's Mailing Address (No PO Boxes Please):

Address Line 1

City

State / Province / Region

Postal Code

Please note, the phone will be shipped to the provided address. While the phone and one-year plan are free, shipping fees may apply. Phones cannot be shipped to PO boxes, as our shipping system is through Purolator, who does not send to PO Boxes.