OPACC - Membership

ONLINE MEMBERSHIP FORM

Please complete the form in full. You will receive a confirmation email once the form has been received.

First name
Last name
Address:
City:
Province:
Postal Code:
Phone:
Email Address:
Are you:	Parent Bereaved Parent Other (please indicate below)
Other:
Child's name:
Date of Diagnosis Month/Day/Year:
Type of Cancer:	AML ALL Neuroblastoma Wilm's Tumor Medulablastoma Other (please indicate below)
Other:
Is your child:	In treatment Off treatment In follow-up clinic Deceased
If child is deceased, please tell us what date your child got his/her wings. Month/Day/Year
Current range of child with cancer:	0-3 4-6 7-10 11-12 13-15 16+
Are there other children in your family?	Yes No
If "yes", please indicate how many other children there are in the family:	1 2 3 4 5 6+
Current age range of other children:	0-3 4-6 7-10 11-12 13-15 16+
Would you like to provide the names of your other children?	Yes No
If "yes" to above, please indicate names of other children in your family.
Treatment Centre	The Hospital for Sick Children, Toronto Children’s Hospital of Eastern Ontario, Ottawa Children’s Hospital of Western Ontario, London McMaster Children's Hospital, Hamilton Kingston General Hospital Other
If you have indicated "other" what hospital was child treated at?
Do you use a satellite centre?	Yes No
If "yes" to above, please indicate which satellite centre you use.	Scarborough/GTA East: Rouge Valley Centenary Mississauga/GTA West: Credit Valley Hospital Kitchener-Waterloo: Grand River Hospital Simcoe County/Muskoka: Orillia Soldiers’ Memorial Hospital, Orillia Sudbury/North Bay/Northern Ontario: Sudbury Regional Hospital Corporation Windsor: Hotel Dieu Grace Hospital None of the above
Are you currently the member of a support group?	Yes No
If "yes" to please indicate name of support group.
Does your child/children attend any cancer camps?	Yes No
If "yes" please indicate which camp.	Camp Ooch Camp Trillium Camp Quality
Would you like to receive our newsletter via email?	Yes No
What more would you like to see on our website?	Stories written by parents More resources More services More information on groups Information on local and regional events Nothing - site is great
Do you have any suggestions regarding our website?
Would you be interested in connecting with another parent who's child has been recently diagnosed?	Yes (a representative from OPACC would contact in advance for your approval) No
Would you be interested in being part of a committee?	Yes No
If "yes" to please indicate which committee interests you (a OPACC representative will contact you).	Fund Development Events Resources Medical (professional and non medical welcome)
Due to current privacy regulations, we require your approval in order to send you emails and organizational updates. Your personal information will not be given out without your permission. Please check your approval.	Yes No
Please indicate date form completed. Month/Day/Date

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