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See how your donations help families, empower children and create brighter futures for children with cancer.
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Learn how we’ve been shining a light on childhood cancer in Canada since 1987.
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EmPower Pack Form
Name
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Please fill out the fields below to register with Childhood Cancer Canada.
Parent / Guardian information
Parent / Guardian Name
(Required)
Parent / Guardian First Name
Parent / Guardian Last Name
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
Address Line 2
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
Second Parent / Guardian Information
Second Parent / Guardian Name
Second Parent / Guardian First Name
Second Parent / Guardian Last Name
Email
Phone
Address
Street Address
Address Line 2
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
Cancer Hero's Information
Name
(Required)
Child's First Name
Child's Last Name
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
Male
Female
Another gender
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 (e.g., First Nations, Metis, Inuit, etc.)
Other
Diagnosis
(Required)
Date of Diagnosis
(Required)
Please confirm that your child is in:
(Required)
Active cancer treatment
Follow-up / After Care
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
University of Alberta
Vancouver Children's Hospital
Victoria General Hospital
Vitalite Health Network
Other
Name of Social Worker
(Required)
Social Worker First Name
Social Worker Last Name
Email
(Required)
Enter Email
Confirm Email
Sibling #1 Name
Sibling #1 Age
Sibling #2 Name
Sibling #2 Age
Sibling #3 Name
Sibling #3 Age
More than 3 siblings? Please add their names and ages below.
Would you like to be invited to local events and family outings?
(Required)
Yes
No
Do you want to receive a tablet for your child? Please note that children under 3 years of age will not be provided with a tablet.
(Required)
Yes
No
Would you like to receive important information from Childhood Cancer Canada?
(Required)
Yes
No
Preferred Language
English
French
Is there anything else you would like to tell us about yourself:
How did you hear about Childhood Cancer Canada?*
Hospital
Social Worker
Support Group
Internet Search
Social Media
Event
Other
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First Choice
Second Choice
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