Online Application

Email us at chaletmalouin@mts.net or call us at 1-204-347-5753 for Martha or Gisele for more information.

Chalet Malouin
Online Housing Application

* Indicates required field

Applicant's Name *

First

Last

Co-Applicant's Name *

First

Last

Applicant's Date of Birth *

Applicant's Address *

Line 1

Line 2

City

State

Zip Code

Country

Co-Applicant's Date of Birth *

Home Phone Number *

Marrital Status *

Emergency Contact or Person Responsible *

First

Last

Home Phone Number *

Contact Person's Address *

Line 1

Line 2

City

State

Zip Code

Country

Work Phone Number *

Cell Phone Number *

Email *

Type of room that you would prefer *

Bachelor - Elderly Person Housing One Bedroom - Elderly Person Housing Two Bedroom - Elderly Person Housing Bachelor - Assisted Living Bachelor - Supportive Housing Adjoining Bachelor Apartments- Assisted Living/Supportive Housing

Are you currently receiving Home Care Services? *

Yes, I am currently receiving Home Care Services. No, I am not currently receiving Home Care Services. What are Home Care Services?

If you are currently receiving Home Care Services, who is your Home Care Case Coordinator? *

First

Last

Phone Number *

Submit

Independent Living

Assisted & Supportive Care