Forms Portal

Families / All Categories

Hearing Aid Claim Form

Hearing aid pre-approval/claim form.

Department/Crown:Families

High Fidelity Wraparound Registration Letter

The letter gathers basic information from training registrants (name, address, dietary concerns, etc).

Department/Crown:Families

Housing Program Contribution Agreement with Appendices (Metis Housing)

An agreement between MHRC and the organization that stipulates the terms.

Department/Crown:Families

IDL1 Letter - Excess Income No Benefits Issued

Letter sent explaining no benefits will be issued as earnings exceed EIA budget.

Department/Crown:Families

Categories:Families, Financial Assistance

In-Home Respite - Guide for Parents

This document informs parents about in-home respite for a child receiving support through Children's disABILITY Services. The guide is accompanied by a form requesting descriptive information about a child's care, routines and activity interests, behavioural issues, to be completed by parents and the direct service provider.

Department/Crown:Families

Categories:Application, Families

Inclusion Support Program - Consent for Release of Personal Information and/or Personal Health Information

This document is a template of the Consent Form granted by a parent/guardian to release personal information and/or personal health information for a child participating in the ELCC Inclusion Support Program.

Departments/Crowns:Education and Early Childhood Learning, Families

Category:Families

Inclusion Support Program - Individual Program Plan

This form is a detailed Individual Program Plan for a child participating in the Early Learning and Child Care Inclusion Support Program. The document includes information about the medical needs of the child and records details of actions for short and long term planning.

Departments/Crowns:Education and Early Childhood Learning, Families

Category:Families

Inclusion Support Program - Staffing Grant Payment Form

The staffing Grant Payment Form reports the children's attendance and salary and benefits paid under the Inclusion Support Program. The child care facility completes this form every four week billing to claim approved grant funding under the program.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Application, Families

Inclusion Support Program Eligibility Application

This policy outlines the eligibility criteria for the Inclusion Support Program (ISP) as it applies to children, families and facilities, as well as the related procedures.

Departments/Crowns:Education and Early Childhood Learning, Families

Category:Families

Inclusion Support Program Eligibility Application

This form is required by the ELCC Program to determine eligibility for supports under the Inclusion Support Program.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Application, Families

Inclusion Support Program Guaranteed Space Payment Application

This document is a template of a Guaranteed Space Payment Application form required for a child participating in an Inclusion Support Program delivered by a licensed ELCC family child care provider.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Families, Financial Assistance

Inclusion Support Program Letter to Centres

This letter to child care centres introduces the Inclusion Support Program policy for eligibility and application process.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Families, Financial Assistance

Inclusion Support Program Service Planning Request for Child Care Facilities

This form must be submitted by child care facilities to access services under the Inclusion Support Program.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Application, Families

Inclusion Support Program Staffing Grant Application

This document is a Staffing Grant Application form requesting Early Learning and Child Care funding for staff to support child(ren) participating in a Inclusion Support Program delivered by a licensed child care facility in Manitoba.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Families, Financial Assistance

Income Assistance Review

Employment and Income Assistance requires a review of the circumstances of each income assistance client.

Department/Crown:Families

Categories:Families, Financial Assistance

Income Declaration

This form is a full declaration of employment income and expenses at each month end, prior to any calculations of EIA eligibility for the upcoming month, or payment of any assistance. EIA participants are asked to forward this form with original cheque stubs and payment receipts after receiving the last income for the month.

Department/Crown:Families

Individual Client Action Plan

This 2011 Employment and Income Assistance circular reminds staff to ensure that Client Action Plans are current, signed and given as a copy to the participant.

Department/Crown:Families

Categories:Families, Financial Assistance

individual Program Plan

This form is part of the child in care file, It describes the medical professionals that are engaged in the child life, any assessments that have been done and any changes in the child's life. It is filled out by the caseworker on agency letterhead.

Department/Crown:Families

Category:Families

Infant Less than 12 weeks of Age - Exemption Request Checklist

This form is required to request an age exemption for a child less than 12 weeks of age to attend a Manitoba licensed child care facility.

Departments/Crowns:Education and Early Childhood Learning, Families

Category:Families

Information and Application for a warrant to search for a child (CFS-23)

If there is reasonable grounds to believe a child might be in need of protection, a judge will grant this warrant to allow peace officers to search for the child.This is a statutory regulated form embedded in The Child and Family Services Regulation. This is an agency form and would not be filled out by the general public.

Department/Crown:Families

Category:Families

Information and Application to obtain a warrant to apprehend an absconded child (CFS-25)

This warrant entitles a peace officer to apprehend and return a child in care to their placement if they run away. This is a statutory regulated form embedded in The Child and Family Services Regulation. It I s a form that would only be filled out by a CFS agency and/or a peace officer.

Department/Crown:Families

Category:Families

Information Booklet Full Citizenship

An introduction to A Manitoba Provincial Strategy On Disability

Department/Crown:Families

Categories:Families, Financial Assistance, Health

Information Disclosure Statement (CDS)

This form is completed by parents and guardians of children enrolled on Children's disABILITY Services to provide their consent for a referral to Behaviour Psychology Services. This form also provides parents and guardian information on Behaviour Psychology Services, their role in the service as well as information regarding confidentiality.

Department/Crown:Families

Information Disclosure Statement (CLDS-SDM)

This form is completed by the substitute decision maker for a Community LIving disABILITY Services participant to provide their consent for a referral to Behaviour Psychology Services. This form also provides substitute decision maker information on Behaviour Psychology Services, their role in the service as well as information regarding confidentiality.

Department/Crown:Families

Information for Individuals Applying for a Self-Check Mail Adult Abuse Registry Check: Checklist

The Registrar of the Adult Abuse Registry, is obtaining personal information so that the Registrar can conduct an Adult Abuse Registry check. The Registrar will also use this information to update the Adult Abuse Registry.

Department/Crown:Families

Categories:Application, Families

Information for Internationally Educated Applicants

This document provides detailed information for an Early Childhood Educator (ECE) who was educated outside Canada (internationally-educated) on what is required to apply and become classified as a Child Care Assistant, ECE II or ECE III in Manitoba.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Certification, Education and Training, Families

Information on the Classification of early Childhood Educators and Child Care Assistants

This document provides detailed information about classification (upgrades and re-issue) of early childhood educators (ECE) and child care assistants, including the application process, education requirements, and equivalency assessments. This policy also outlines the proportion of trained professionals (ECE's) required in licensed early learning and child care centres and nursery schools in Manitoba.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Certification, Education and Training, Families

INL1 Letter - Information Requested

Letter sent when information is required from a client.

Department/Crown:Families

Categories:Families, Financial Assistance

INL2 Letter - Information Requested 2nd Letter

Letter sent when requesting information from a client.

Department/Crown:Families

Categories:Families, Financial Assistance

Insight Evaluation Guide

This guide outlines the way in which HCMO's evaluation forms are to be administered with InSight Mentor Program participants.

Department/Crown:Families

InSight Mentor Program - Aftercare Contact Tracking Form

This form tracks contact with the InSight Mentor Program made by former participants who have graduated from the program.

Department/Crown:Families

Insight Mentoring Program: File Closure Form

This form is completed upon a participant's exit of the program, either due to graduation or other means of departure from the program.

Department/Crown:Families

Insight Mentoring Program: Getting to Know You

This is the InSight Mentor Program intake form, which is completed with new participants. Information about the participant's health, substance use, current or most recent pregnancy, and use of community services.

Department/Crown:Families

Insight Mentoring Program: Getting to Know Your Baby

This form is completed with new InSight Mentor Program participants to gather information about the participant's pregnancy and birth outcomes of their baby.

Department/Crown:Families

Insight Mentoring Program: Goals Sheet

This form is completed with InSight Mentor Program participants every four months to identify and track progress on goals set by the participant.

Department/Crown:Families

Insight Mentoring Program: Referral Decision Record

This form is completed upon receipt of a referral or transfer to the InSight Mentor Program to determine the decision made on eligibility, and to record enrollment.

Department/Crown:Families

Insight Mentoring Program: Year 1 Check-In

This form is completed with InSight Mentor Program participants after they have been in the program for one year, to capture changes to their life circumstances since intake.

Department/Crown:Families

Insight Mentoring Program: Year 2 Check-In

This form is completed with InSight Mentor Program participants after they have been in the program for two years, to capture changes to their life circumstances since intake, and since completing the Year 1 Check-In.

Department/Crown:Families

Insight Mentoring Program: Year 3 Check-In

This form is completed with InSight Mentor Program participants after they have been in the program for three years, to capture changes to their life circumstances since intake, and since completing the Year 2 Check-In. This form also functions as an exit interview, since participants complete the program after three years.

Department/Crown:Families

Insight Program and Policy Guide

This policy guide provides an overview of the InSight Mentor Program, as revised from the P-CAP (evidence-based program model) Manual. Includes information on hiring and training staff, referring and recruiting participants, program administration, information on working with participants, and relevant resources.

Department/Crown:Families

Insight Program: Evaluation Consent Form

This form is signed by InSight Program Participants who volunteer to participate in Healthy Child Manitoba's evaluation of the InSight Mentor Program. The form outlines the ways in which the participant's personal information is collected and protected.

Department/Crown:Families

Inspection Checklist - Child Care Centres and Nursery Schools

The Inspection Checklist for Child Care Centres and Nursery Schools is a form filled out by the Child Care Coordinator to license the centre or nursery school and is signed by the licensee when complete.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Families, Licence

Inspection checklist Family Child Care Homes

The Inspection Checklist for Family Child Care Homes is a form filled out by the Child Care Coordinator to license the home and is signed by the licensee when complete.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Families, Licence

Inspection Checklist Group Child Care Homes

The Inspection Checklist for Group Child Care Homes is a form filled out by the Child Care Coordinator to license the home and is signed by the licensees when complete.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Families, Licence

Intent Not to Meet Work Expectations Form

This document informs an EIA participant of a reduction in their monthly benefit when they choose not to meet work expectations. The form describes the consequences of not following the Personal Job Plan.

Department/Crown:Families

Categories:Employment, Families, Financial Assistance

Job Search Activity Report

Employment and Income Assistance job search activity report form to be completed by participants.

Department/Crown:Families

Categories:Families, Financial Assistance

Key Standards/Comments Sheet for Child Care Centres

Form used by child care coordinators when monitoring a child care centre to record non-compliances with key standards, observations, discussions held or agreements made. The facility representative is required to sign the form.

Department/Crown:Families

Categories:Families, Licence

Key Standards/Comments Sheet for Famiy Child Care Homes

Form used by child care coordinators when monitoring a child care facility to record non-compliances with key standards, observations, discussions held or agreements made. The licensees is required to sign the form.

Department/Crown:Families

Categories:Families, Licence

Lennox Bell to EIA Letter re Billing

Only HSC staff can refer individuals to Lennox Bell Place, and individuals must be approved by the Director of Social Work and Utilization before admission.

Department/Crown:Families

Categories:Families, Financial Assistance

Letter of Understanding (Home Modification)

This document is a sample letter sent by the Disability and Health Supports Unit to notify of the approval of a home modification request for a child open to Children's disABILITY Services.

Department/Crown:Families

Letter to the Adult Abuse Registry (Requesting Access) Template

The Adult Abuse Registry unit uses this form to comply with Section 41(4) of The Adult Abuse Registry Act that states:

On application by an employer or other person, the registrar must disclose to the applicant whether the name of a person is entered in the registry.

Department/Crown:Families

Category:Families

Letter to the Child Abuse registry (Requesting Access) - Template

Organizations may apply for direct access to the child abuse registry by completing a letter of application which allows volunteers, students and work placements within the organization to be eligible for a fee exemption.

Department/Crown:Families

Category:Application

Licence Application

Application form to become licensed as an early learning and child care centre, nursery school, family child care home, or group child care home.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Application, Families, Licence

License Application Package

This document outlines requirements to be submitted to Manitoba's ELCC Program when applying for a licence for a child care centre or nursery school. The application package includes basic information about the sponsoring group/individual, type of child care operation, number and ages of children to be cared for, policies, operating procedures, and floor plans.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Families, Licence

Licensee Background Check Verification Declaration - Child Care Centres and Nursery Schools

This document is the Licensee Background Check Verification Declaration form that is required for all new employees and nursery school parent volunteers at licensed Manitoba early learning and child care centres and nursery schools.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Families, Licence

Local EDI Coordinator Instructions

EDI implementation instructions for Local EDI Coordinators.

Department/Crown:Families

Category:Education and Training

Manitoba Early Learning and Child Care Wage Adjustment Application

The Wage Adjustment Application form records salary information and hours worked by employees, specifically Early Child Care Educators and Child Care Assistants-in-Training, working at Manitoba's licensed child care facilities. It is part of a ELCC facility request for wage adjustment funding assistance.

Departments/Crowns:Education and Early Childhood Learning, Families

Categories:Application, Families, Financial Assistance

Manitoba Key Worker Alliance Inventory (Family)

A survey collecting information on the family's perception of the family/Key Worker relationship.

Department/Crown:Families

Manitoba Key Worker Check-in/Exit Form

This form is completed at the 6 month, 18 month, and exit stages of the program. It collects information on current services/supports, caregiver work attendance, caregiver understanding of FASD, caregiver stress levels, family outcomes and satisfaction with the program; and their child's school attendance.

Department/Crown:Families

Manitoba Key Worker Closure Form

This form tracks when families leave the program and the reason for file closure.

Department/Crown:Families

Manitoba Key Worker Closure Policy

This policy establishes the extent of service provided to families within the program and provides staff with procedures to help them guide families towards self sufficiency.

Department/Crown:Families

Manitoba Key Worker Evaluation Guide

This guide provides program staff with all the information on how to complete Manitoba Key Worker Program evaluation forms.

Department/Crown:Families

Manitoba Key Worker Family Quality of Life Survey

A survey collecting information on family interaction, parenting, emotional well-being, physical/material well-being, and disability-related support.

Department/Crown:Families

Manitoba Key Worker Follow-Up Form

This form is completed 3 months after a family has exited the program. It collects information on current services/supports, caregiver work attendance, and if the family has been in contact with their Key Worker since exiting the program.

Department/Crown:Families

Manitoba Key Worker Intake Policy

This policy assists staff to respond to requests for service and referrals to the program, as well as requests for presentations on FASD from the community.

Department/Crown:Families

Manitoba Key Worker Monthly Caseload Summary

This form tracks the amount of time each month that staff spend with each family on their caseload.

Department/Crown:Families

Manitoba Key Worker Monthly Service Request Summary

This form tracks the number of service requests received by the program in a one month period.

Department/Crown:Families

Manitoba Key Worker Monthly Time Summary

Collects information, over a one month period, to determine the amount of time each staff spends performing the duties associated with their role as Key Workers.

Department/Crown:Families

Manitoba Key Worker PES

A survey collecting information on the family's perceived ability to interact with service systems, parent organizations, and the services their child and family receive.

Department/Crown:Families

Manitoba Key Worker Program - Orientation Guide

The purpose of this document is to clarify the role, function, and framework for practice of Key Workers by presenting the standards that underpin the Key Worker program in Manitoba.

Department/Crown:Families

Manitoba Key Worker Training Overview

This document outlines all of the required reading and training that new Key Workers are required to complete.

Department/Crown:Families

Manitoba Key Worker Welcome Form

This form collects background information on the family and their child, family connection to services/supports, caregiver work attendance, caregiver understanding of FASD and stress levels; and their child's school attendance.

Department/Crown:Families

Manitoba Key Worker Working Alliance Inventory (Key Worker)

A survey collecting information on the Key Worker's perception of the family/Key Worker relationship.

Department/Crown:Families

Manitoba Post-Adoption Services Adoptive Parent(s) of Minor Child Application

This application is for adoptive parents of a minor child (under 18 years of age) to apply for post-adoption services. Post-Adoption Services include registering for contact with and search services for the adoptee's birth family members.

Department/Crown:Families

Category:Families

Manitoba Post-Adoption Services Adoptive Parent/Sibling Application (when Adoptee is Deceased)

This application is for adoptive parents and adult adoptive siblings (18+ years of age) to apply for post-adoption services when the adoptee is deceased. Post-Adoption Services include registering for contact with and search services for the deceased adoptee's birth family members.

Department/Crown:Families

Category:Families

Manitoba Post-Adoption Services Adult Adoptee Application

This application is for adult adoptees (18+ years of age) to apply for post-adoption services. Post-Adoption Services include requesting birth documents, requesting a non-identifying Social History and registering for contact with and search services for birth family members.

Department/Crown:Families

Category:Families

Manitoba Post-Adoption Services Adult Birth Sibling Application

This application is for birth siblings (18 + years of age) of a Manitoba adoptee to apply for post-adoption services. Post-Adoption Services include requesting an adoptive family profile and registering for contact with and search services for the adoptee.

Department/Crown:Families

Category:Families

Manitoba Post-Adoption Services Adult Child of an Adoptee Application (When Adoptee is Deceased)

Application for adult children of deceased adoptees to request non-identifying social history information and/or request contact with and/or search services with the adoptee's birth family.

Department/Crown:Families

Category:Families

Manitoba Post-Adoption Services Birth Grandparent Application (when Birth Parent is Deceased)

This application is for birth grandparents to apply for post-adoption services when a birth parent is deceased. Post-Adoption Services include requesting an adoptive family profile and registering for contact with and search services for the adoptee.

Department/Crown:Families

Category:Families

Manitoba Provincial Health & Life Safety Policy for Adult Residential Care Homes

This document provides guidance to service provider agencies and private operators of home shares (i.e., host family homes) regarding the minimum health and safety standards required by Residential Care Licensing for these homes.

Department/Crown:Families

Category:Families

Manitoba Status of Women Secretariat - Publication Requests

To order publications produced by the Manitoba Status of Women Secretariat, please contact:

Manitoba Status of Women Secretariat

409-401 York Avenue (Norquay Building)

Winnipeg MB R3C 0P8

Phone: (204) 945-6281 Toll-free: 1-800-263-0234

msw@gov.mb.ca

Departments/Crowns:Families, Sport, Culture and Heritage

Manitoba Women's Advisory Council Events - RSVP sheet

To register for Manitoba Women's Advisory Council events, please contact:

Manitoba Status of Women Secretariat

409-401 York Avenue (Norquay Building)

Winnipeg MB R3C 0P8

Phone: (204) 945-6281 Toll-free: 1-800-263-0234

msw@gov.mb.ca

Departments/Crowns:Families, Sport, Culture and Heritage

Manitoba Women's Advisory Council Events - Vendor Information

Contact:

Manitoba Status of Women Secretariat

409-401 York Avenue (Norquay Building)

Winnipeg MB R3C 0P8

Phone: (204) 945-6281 Toll-free: 1-800-263-0234

msw@gov.mb.ca

Departments/Crowns:Families, Sport, Culture and Heritage

Marketabilities Participant Referral Information

This document is a Participant Referral Information form to be completed by EIA staff who are referring an EIA participant to participate in the Employability Assistance for People with Disabilities program (formerly marketAbilities).

Department/Crown:Families

Categories:Families, Financial Assistance

MCB Application Form

Use this form to apply for the benefit. NOTE: To apply for the Manitoba Child benefit you need to understand the different types of benefits for different types of families.

Department/Crown:Families

Categories:Application, Benefits, Families, Financial Assistance

MDC - Agency Discharge Protocol

Manitoba Developmental Centre agency discharge protocol form to be completed by the agency or community care provider prior to discharge.

Department/Crown:Families

Category:Families

MDC - Agency Discharge Protocol (A-152)

Department/Crown:Families

Category:Families

MDC - Consent for Disclosure of Personal Health Information Form

Manitoba Developmental Centre's Consent for Disclosure of Personal Health Information form. This form documents consent by a resident or substitute decision-maker to disclose personal health information.

Department/Crown:Families

Category:Application

MDC - Consent for Treatment and Procedures

Manitoba Developmental Centre's Consent for Medical Treatment and Procedures form. This form documents consent by a resident or substitute decision-maker to specified medical treatment or procedures.

Department/Crown:Families

MDC - Consultation Referral record

Manitoba Developmental Centre external medical or professional consultation/referral record of care provided to a specified resident.

Department/Crown:Families

Categories:Application, Families

MDC - Dental Appointments

Manitoba Developmental Centre's Dental Appointments Policy. Residents of the Manitoba Developmental Centre will be provided with routine oral health assessments and/or required dental treatment.

Department/Crown:Families

MDC - release of Body

Manitoba Developmental Centre's (MDC) Release of Body form. This form documents directions to the funeral home about the requirements associated with the release of a deceased resident's body.

Department/Crown:Families

MDC - TRON Photo Release Form

Manitoba Developmental Centre's (MDC) Therapeutic Recreation Outreach Network (TRON) Photo & Artwork Display Release form. This form documents permission for the use of participant photographs or artwork in TRON communication materials, displays or events such as art shows.

Department/Crown:Families

MDC - Visitors

Manitoba Developmental Centre's Visitors Policy. Residents will be supported to establish and maintain meaningful social relationships through visits from family members, friends and other supportive individuals in a safe and therapeutic environment.

Department/Crown:Families

MDC - Volunteer Application Form

Manitoba Developmental Centre's (MDC) Volunteer Service Application form. This is the application form for those wishing to volunteer at MDC.

Department/Crown:Families

MDC - Volunteer Program

Manitoba Developmental Centre's Volunteer Program Policy. This policy outlines how volunteers are to be screened, oriented, trained, placed, evaluated and recognized.

Department/Crown:Families

MDC -Community Transition Day Pass/LOA Form (CR-43)

Manitoba Developmental Centre's Community Transition Daypass/Leave of Absence Form. This form documents the details of a resident's Leave of Absence.

Department/Crown:Families

Category:Application

MDC Admissions Policy

Manitoba Developmental Centre - Substitute Decision Maker Personal Consent Form

Department/Crown:Families

Category:Families

MDC Discharge Checklist

Manitoba Developmental Centre's Resident Discharge Checklist.

Department/Crown:Families

MDC Discharge Policy

Manitoba Developmental Centre's Discharge Policy. Discharge is done in a manner that promotes individual growth and identifies personal strengths, preferences, needs, required services and outcomes that ultimately enhance their quality of life.

Department/Crown:Families

Category:Families