Volunteer Application

This form is for Healthcare Professionals who wish to refer their patients/clients.
If you are not a Healthcare Professional, please click here

PLEASE ENSURE THAT YOU FILL IN ALL OF THE REQUESTED INFORMATION!

Failure to complete the form in its entirety will result in delays or an inability to get your patients the services you are seeking on their behalf.

The information you provide, is treated as confidential and used by CanCare staff to address the needs of your patient and will only be provided to your patient's dedicated volunteer so they can connect with your patient and support their needs.

Requester Information

Name of Organization

Name of Individual Completing This Form

Phone

Do you want CanCare follow up?

Have you referred someone to us before?

Is the person being referred expecting a call from CanCare?

Client Information

Client is a...

Patient

Family member / caregiver

Client First Name

Client Last Name

Client Email

Client Date of Birth

Country

Address

Apt/Ste

City

State

Zip Code

County

Client Preferred Phone Number

One phone number is required.

Client Gender

Date of diagnosis?

Cancer Type

Describe other cancer type

Stage of Cancer?

Treatment

Reason for Referral or additional information to assist us in making a quality match for your client

Is the patient open to a match with a volunteer with a different type of cancer?

Healthcare Referral Form

This form is for Healthcare Professionals who wish to refer their patients/clients. If you are not a Healthcare Professional, please click here

Requester Information

Client Information

This form is for Healthcare Professionals who wish to refer their patients/clients.
If you are not a Healthcare Professional, please click here