Skip to content
Our Impact
See how your donations help families, empower children and create brighter futures for children with cancer.
How We Help
Stories
Annual Report
Programs & Research We Support
Programs & Support
Explore all the ways we’re supporting children with cancer and their families.
Apply For Support
Survivor Scholarship
EmPower Pack
Emergency Fund
Additional Resources for Families
Benevolent Fund
How to Give?
Explore ways to donate, fundraise or volunteer, and make a significant impact today.
Plan a Fundraiser
Partner with Us
Events
Donate
Tribute
About Us
Learn how we’ve been shining a light on childhood cancer in Canada since 1987.
Mission and History
Our People
Contact Us
Donate
Search
Search
Emergency Fund Form
Email
This field is for validation purposes and should be left unchanged.
This field is hidden when viewing the form
Next Steps: Sync an Email Add-On
To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.
Social Worker or Interlink Nurse or Nurse Practitioner or Oncologist:
Social Worker or Interlink Nurse or Nurse Practioner or Oncologist Name
(Required)
First Name
Last
Name of Hospital
(Required)
Alberta Children's Hospital
BC Children’s Hospital
Cancer Care Manitoba
Canuck Place
Children's Hospital of Eastern Ontario (CHEO)
CHU Saint Justine
CHU de Quebec-Université Laval
Credit Valley Hospital
Health Science Center (MB)
Holland Bloorview Kids Rehab
Horizon Health
IWK Health Centre
Janeway Children's Hospital
Jim Pattison Children’s Hospital
Kingston Health Sciences Centre
Leucan
London Health & Science Children's Hospital
McMaster Children's Hospital
Montreal Children's Hospital
Princess Margaret Hospital
Saint John Regional Hospital
Sick Kids
Southlake Regional Health Centre Hospital
Stollery Children's Hospital
Surrey Memorial Hospital
The Children's Hospital of Winnipeg
University of Alberta Hospital
Vancouver Children's Hospital
Victoria General Hospital
Vitalite Health Network
OTHER
Email
(Required)
Phone
(Required)
Child / Patient
Child/Patient Name
(Required)
Child First Name
Child Last Name
Diagnosis
(Required)
Date of Diagnosis
(Required)
Date of Birth
MM slash DD slash YYYY
Please confirm that your child is in:
(Required)
Active cancer treatment
Follow-up / After Care
Gender
(Required)
Male
Female
Prefer not to answer
Ethnic Origin
(Required)
Caucasian
Black/African/Caribbean
Latin American ( e.g., Costa Rican, Brazilian, Columbian, etc.)
South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.)
Middle Eastern (e.g., Saudi Arabian, Iranian, Egyptian, etc.)
East Asian (e.g., Japanese, Vietnamese, etc.)
Indigenous (First Nations, Metis, Inuit)
Other
Parent, Legal Guardian or Caregiver:
Parent, Legal Guardian or Caregiver Name
(Required)
Parent, Legal Guardian or Caregiver First Name
Parent, Legal Guardian or Caregiver Last Name
Email
(Required)
Phone
(Required)
Relationship between yourself and the other parent, legal guardian, or caregiver:
(Required)
Address
(Required)
Street Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Preferred Language
(Required)
English
French
Gross Household Income Statement
(Required)
Combined Household Income of $59,999 and under per year (post-diagnosis)
Combined Household Income of $60,000 and over per year (post-diagnosis)
Please provide a brief description of how these funds will help your family:
(Required)
Would you like to receive communications from Childhood Cancer Canada?
(Required)
Yes
No
Would you like to be invited to local events & family outings?
(Required)
Yes
No
Date
MM slash DD slash YYYY
