New to YACC
Thank you for your interest in YACC and our programs and services. If you have been diagnosed with cancer at 39 or younger and you are currently over 18 - or if you know someone that has been diagnosed - please complete the form below and we will get back to you as soon as we can with more information to help.

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.
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Your Name *
If you are completing this form on behalf of someone else, what is their name?
If you are completing this form on behalf of someone else, what is your relationship to them?
Email (please enter the preferred email address where we can contact you and send the most appropriate information to help) *
Diagnosis *
Age at diagnosis *
Date of birth *
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Current City *
Province *
How did you hear about YACC? *
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