Are you new to Young Adult Cancer Canada?
You've found the right spot! Cancer sucks, we're sorry that you need us- but so glad you found us. Through filling out this form, we'll send you more about Young Adult Cancer Canada (YACC) and our programs and services. 

Our services are for folks that have been diagnosed with cancer at age 39 or younger, and are currently between the ages of 18 and 40ish. We also have some support options for supporters of a young adult with cancer that's roughly in the same age group/stage of life (for example, for partners, siblings, and friends- but not for parents/grandparents).

If that's you- please complete the form below and we'll get back to you soon with more information to help. You can also complete this form on behalf of someone else if they've provided consent.

Thank you!

The YACC Program Team

Note: If you need accommodations made to complete this form, please let us know by emailing: connect@youngadultcancer.ca or calling: 709.579.7325 or Toll-free: 1.877.571.7325 and we will find a way that works for you.
Sign in to Google to save your progress. Learn more
If you are completing this form on behalf of someone else, what is your name?
If you are completing this form on behalf of someone else, what is your relationship to them?
Please note, that after this question- answer as though you are the person you are completing the form for. Thank you!
First Name *
Last Name *
Email  *
Please enter the preferred email address where we can contact you and send the most appropriate information to help. Keep an eye on your spam folder!
Phone Number  *
We have had a lot of bots filling out our forms lately, so this might be used to verify that you are real. 
Format: ###-###-####
City *
Please share the city where you live now.
Province/Territory (or State) *
Please share the province/territory/state where you live now.
Country *
Please share the country where you live now.
Do you live near(ish) any of the following cities?
We run regular in-person events in these cities- so we want you to be in the know if you consider it feasible to drive there for something special. 
Birthdate *
MM
/
DD
/
YYYY
Pronouns
What pronouns would you like us to use?
Gender Identity *
Required
In this next section, Y = Yes & N = No.
It makes it a little easier for us to manage this information. Thanks for rolling with us!
Have you been diagnosed with cancer before the age of 40? *
Are you supporting someone diagnosed with cancer before the age of 40 while in a similar stage of life?  *
For example, you may be their partner, sibling, friend, etc. but not their parent or grandparent.
Are you the parent or guardian figure of someone diagnosed with cancer before the age of 40? *
For example, you might be their parent, grandparent, aunt/uncle, etc.
If you are a supporter of a young adult diagnosed with cancer- what is their name?
First & last is helpful if you have that information!
If you are a supporter of a young adult diagnosed with cancer- what is your relationship?
For example, you might put "spouse" here or "parent".
Are you a healthcare provider? *
Diagnosis(es) *
Provide what feels comfortable.
Age at diagnosis *
You may have received multiple diagnoses or recurrences of disease. Please share with us the age you were at your first diagnosis.
How did you hear about YACC? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Young Adult Cancer Canada.

Does this form look suspicious? Report

Google Forms