Transportation Forms

Transportation Forms & Application Procedures

SHC Intake Form
This document is to obtain information for treatment. This applicattion can be completed on your computer (you can save data typed into the form).
Transportation Application Procedure
This guideline has been developed for Shrine Clubs and Nobles when referring a child to the Shriner’s Canadian Hospital for Children and the Shrine Boston Burns Institute.
Policy Agreement between Family and Shriner
This document is to obtain information needed to define the extent of financial support required.
Consent for Treatment (English Version)
This document is to obtain information for treatment. (French Version)

Luxor Transportation Chairmen

General Chairman
Wayne Cormier
342 King Avenue, Bathurst, NB E2A 1P3
Phone: (Home) 506-546-1012 (Cell) 506-547-5246
Office: 888-546-9841 (Fax) 888-371-0676

Shrine Club Contacts

Charlotte Co. Shrine Club
James McCollum
97 Maple Crescent, Nerepis, NB E5K 3V9
Phone: 506-757-8284 Cell: 506-640-1934

Fredericton Shrine Club
Don Demmings, PP
327 Regent St. Apt. 308, Fredericton, NB E3B 9V3
(Cell) 506-260-6200

Miramichi Shrine Club
Robert Gregan
Water St., Miramichi, NB E1N 1L8
Phone: 506-773-7576 ext. 2642 (Fax) 506-773-8883

Moncton Shrine Club
Robert L. MacQuarrie
212 Sumner Ave., Moncton, NB E1C 8A7
Phone: 506-384-0929 (Cell) 506-863-3835

North Shore Shrine Club
Michael Kierstead
1152 Vantassell St., Bathurst, NB E2A 4C8
Phone: 506-548-4393 (Cell) 506-545-0474

Saint John Shrine Club
Brian Buckley
9 Buckle Rd., Saint John, NB E2M 6T4
Phone: 506-738-8720

Sussex Shrine Club
Brian Keating
55 Valleyview Cres., Plumsweep, NB E4G 2V3
Phone: 506-433-1034

Upper Saint John River Valley Shrine Club
Gary Dingee
400 West Glassville Rd., Glassville , NB E7L 1W4
Phone: 506-246-6247


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