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?

Your Name

Phone Number

Email Address

Are you the applicant? Yes No

If no: please indicate relationship

Lifeline application information

Full Name *

Service Address *

City/Town *

Postal Code *

Date of Birth

Email Address

Home Phone Number *

Check one that applies to this service address (Why do we need this information?)

Traditional Telephone Landline

Non-traditional (e.g.) VOIP, MagicJack

Cell phone only

Choose Your Lifeline Service Plan

HomeSafe - Wrist

HomeSafe - Pendant Necklace

HomeSafe with AutoAlert Fall detection - Pendant Necklace only

On the Go Mobile Service - Pendant Necklace Only

Installation Preference

In-Home Installation - Our Home Service Technicians will install and test the equipment at your home to provide expert installation.

Contactless Installation - Get Lifeline delivered to your door with professionally guided installation and setup.

Responders (What is a Responder?)

Responder #1

Full Name

Home

Cell

Work

Responder #2

Full Name

Home

Cell

Work

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.

Why do we need this information?

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.

What is a Responder?

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

Call Victoria Lifeline now! (204) 956-6777 or Toll Free: 1-888-722-5222