Local: (204) 956-6777 | Toll Free: 1-888-722-5222
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Local: (204) 956-6777 | Toll Free: 1-888-722-5222

Lifeline Application Form

We're here to help. Apply Today!

If you have decided to ensure your or a loved one’s safety and independence with Lifeline, fill out our application form and we will be in contact shortly. 

How can we reach you?

Name
Are you the applicant?

Lifeline Application Information

Name
Address
Check one that applies to this service address
The type of telephone service the subscriber has will determine the type of communicator unit we install. If you only have a cell phone for example, we would install a wireless communicator unit.
Choose Your Lifeline Service Plan
Installation Preference

Responder #1

Responders are family members, friends or neighbours Lifeline would call to check on you when help is needed.
Name

Responder #2

Name

If you need assistance when filling out this application, please call our office at (204) 956-6777 or toll-free in Manitoba at 1-888-722-5222.
By submitting this information, you authorize Victoria Lifeline to begin the application process and to contact you regarding this service request.

Have you heard about our Refer a Friend Program?

9 out of 10 clients say they would refer Lifeline to a friend. We consider a referral the highest compliment and thank our subscribers!

Anytime you refer a friend to the service, both you and your friend will receive a FREE month.

*Some conditions apply

Two of three men wearing Lifeline button

Contact Info

Victoria Lifeline

Unit #1, 756 Pembina Highway
Winnipeg, Manitoba
R3M 2M7
Office hours: Mon-Fri 9:00 am – 5:00 pm

Local: (204) 956-6777
Toll-free: 1-888-722-5222
Email: info@victorialifeline.ca