This application form is designed to collect personal information for the purpose of assessing eligibility for the Childhood Cancer Canada Health Sciences Scholarship Program. This may include personal, medical, and identification information required to administer the scholarship. By submitting this application, I consent to Childhood Cancer Canada collecting, storing, and using this information solely for the purpose of administering the Scholarship Program and related engagement activities. I attest that the information provided in this application is true and accurate to the best of my knowledge. I confirm my eligibility as a childhood cancer survivor and understand that this information is used to determine scholarship eligibility. I acknowledge that incomplete, inaccurate, or misleading information may impact the outcome of my application.

I, hereby authorize Childhood Cancer Canada to use, reproduce, and/or publish all written and/or visual materials, including photographs that may pertain to me. I understand that this material may be used in various publications, public affairs releases, recruitment materials, and/or for other related endeavors. This material may appear on the Foundation's website, as well a full list of the survivor scholarship recipients will be made available on CCC's website. A notification that I have received a Childhood Cancer Canada scholarship may appear in my local newspaper*. This authorization is continuous and may only be withdrawn by my specific rescinding of this authorization. Consequently, Childhood Cancer Canada may publish materials, use my name (first name only), photograph, and/or make reference to me in any manner that the Foundation deems appropriate in order to promote/publicize service opportunities.