Lifeline Application Form

We're here to help.

If you have made the decision 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. 

Women wearing lifeline button applying on her phone

How can we reach you?

Lifeline application information

(Why do we need this information?)

Choose Your Lifeline Service Plan

Installation Preference

Responders (What is a Responder?)

Responder #1

Responder #2

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.