Home Nutrition Support Program

Please confirm you or your child meet all the eligibility requirements below:

If you have met all eligibility criteria above, please continue to complete the application for financial assistance.  If you need further assistance, please contact your dietitian.

Patient Information

Formula Information

Parent/Guardian 1

Parent/Guardian 2

The IWK Nutrition Support Program needs to collect, use and disclose your name and address to a partnering agency, for the purpose of having nutritional products delivered to your residence. The collection, use, and disclosure of your personal information will be limited to only the information required to manage this specific function. We are committed to protecting your personal health information and will only collect, use or disclose it in accordance with the Personal Health Information Act (PHIA).

Please allow 10 business days for the application to be processed, at which time you will be contacted by your preferred method indicated above. It may take up to 4-6 weeks for the first formula order to be delivered to your home. Your dietitian can assist with arranging formula until this time.