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Phone
This field is for validation purposes and should be left unchanged.
Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Relationship with Cancer*
- I currently have cancer and am in/awaiting treatent or surgery
- I no longer have detectable signs of cancer
- My cancer is in remission
- I am a caregiver to someone with cancer or whose cancer is in remission
- Other
Date of Diagnosis
When was the most recent diagnosis your best guess on the exact date is fine)
MM slash DD slash YYYY
Type of Cancer*
What kind of cancer do/did you or your loved one (if you are a caregiver) have?
Preferred Supports*
What type of programs or services are you most interested in accessing?
- Support groups
- Individual counselling
- Physical exercise/wellness services
- Wig fitting
- Creative Arts & Expression
- Social Programs
- Hospital parking/transportation
- Education & Information
- None of the Above
How did you hear about us?*
- Internet search
- Social Media
- Newspaper/TV/Radio
- Friend or Family
- Healthcare professional
- Prior knowledge
- Other
Is there anything else you would like us to know?*
Confidentiality Agreement*
I agree to the confidentiality agreement
I understand that the information I have provided will be used to determine eligibility for membership and program/service access at the GBCSC, for internal statistical and reporting purposes, and to assist the Centre in planning its programs/activities. I agree that my information will be shared only as needed with staff of the GBCSC, trained volunteers of the GBCSC, service and program providers, and other members of the circle of care for the purpose of providing cancer support programming. Information will not be shared with anyone else or for any other purpose without my written consent, or unless disclosed voluntarily by me. I understand that my information is stored in a secure manner at the GBCSC and/or at the location of partner practitioners and care providers in a secure manner aligning with the governing body of said partner practitioner or care provider.

I further agree to hold in confidence anything of a personal nature that is told to me by others before, during, or following any programs and services administered by the GBCSC, or by individuals with whom I have a relationship that was facilitated through programs and/or services administered by the GBCSC
Liability Release*
I agree the liability release
I understand that my participation in any program or class may result in physical stress, pain, disability, injury or other health risk. I have been encouraged to speak to my health care provider before starting any new exercise program. I am voluntarily choosing to take part in the programs at the Centre at my own risk. I hereby release and agree to not hold liable the Centre, its programs providers, and staff in the event of an accident, injury or illness which might occur because of my taking part in the programs.
Photo & Video Release
I consent to the Photo and Video Release
I understand that photographs, videos and/or recordings may be taken during programs and activities at the Centre with prior notification and that in such instances I will be notified prior to any photo or video recording taking place and will have the opportunity not to appear in said photos/videos. I also understand that these may be used to promote the Centre and its activities and programs. These items are the sole property of the GBCSC, and I relinquish any present or future claim for reimbursement for any reproduction of my likeness of recorded testimonial. I release the GBCSC, its affiliates, employees, representatives, and agents from all claims, demands, costs and liability that may arise from the use of these materials.
Consent to receive information*
I give permission for the Georgian Bay Cancer Support Centre to contact me using the information provided.

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