ThriveAlive - Thrive Alive Interest Form

Thrive Treatment Program

How Does it Work?

Are you Eligible

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Please read eligibility criteria (with a link to the eligibility criteria) before submitting your information. Thrive Alive Foundation will contact you if you are selected

* Indicates required fields

Basic Information

* First Name:

* Last Name:

* Gender:

* Address:

* City:

* Country:

* Province:

* Postal Code:

* Are you a Canadian resident?

Yes

* Daytime Phone Number:

Evening Phone Number:

Mobile Phone Number:

* Email:

* Date of Birth:

* Age:

Medical Information

If selected, you will be required to provide your provincial health care number
as well as supporting documents of your cancer diagnosis which will come
from your medical team.

Medical Referral (What is this?):

* Cancer diagnosis:
(relevant for this application)

* Date of cancer diagnosis:

* Current Treatments:

* Description of services that you are seeking:

Letter of Intent: (What is this?)

Low Income and Household Information

Yes, I am considered low income ()

If selected, you will be required to provide supporting documents as proof

How many persons live in your household?

How many dependents?

by submitting this form I agree to the terms and conditions for this application.

Type the characters you see in the picture below.
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COLLECTION OF INFORMATION / PRIVACY

Any personal information provided to Thrive Alive Foundation is collected, used and disclosed is accordance with the Freedom of Information and Privacy Act or other applicable legislation. Purpose for collecting information: Thrive Alive Foundation will be collecting and using the information to assess and process the application, verify the details of your health case, and for statistical data collection purposes. Personal information will not be sold, traded, given or disclosed to any other body or organization. Personal information will only be collected and used by authorized staff and members of Thrive Alive Foundation to fulfill the purpose for which it was originally collected. Thrive Alive Foundation does not collect personal information unless voluntarily provided for the Thrive Support Program application. All information is required to properly process and review the application, unless clearly specified as OPTIONAL.

DISCLAIMER

Thrive Alive Foundation will not be responsible for harm or loss incurred from receiving care or treatments or products from the health care provider chosen or monetary grant from Thrive Alive Foundation. By submitting this application you, the applicant, release Thrive Alive Foundation from any and all claims related to this application and the use of treatments or products received as a result of it. BY CLICKING SUBMIT, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTOOD ALL TERMS OF APPLICATION AND FURTHER CONSENT TO THE USE OF THE COLLECTION AND USE OF YOUR PERSONAL INFORMATION AND THAT YOU ARE WAIVING YOUR LEGAL RIGHTS TO TAKE LEGAL ACTION AGAINST THRIVE ALIVE FOUNDATION. IT IS AN OFFENCE TO MAKE A FALSE OR MISLEADING STATEMENT IN AN APPLICATION FOR SUPPORT THROUGH A REGISTERED CHARITABLE ORGANIZATION.

I do not agree

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