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Emergency Fund Form
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Social Worker or Interlink Nurse or Nurse Practitioner or Oncologist:
Name
(Required)
First
Last
Name of Hospital
(Required)
Email
(Required)
Phone
(Required)
Child / Patient
Name
(Required)
First
Last
Diagnosis
(Required)
Age
(Required)
Please confirm that your child is in:
(Required)
Active cancer treatment
Follow-up / After Care
Parent, Legal Guardian or Caregiver:
Name
(Required)
First
Last
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
Please provide a brief description of how the 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?
Yes
No
Email
This field is for validation purposes and should be left unchanged.
