beadsofcourage.ca


Parent Interest in the Beads of Courage Program Thank you for your interest in our Beads from a Distance Program. We are honoured to support children and their families from a distance who do not have the opportunity to recive Beads of Courage at their current hospital or in their outpatient clinic. Please fill out this form below and our Beads of Courage Distance Ambassador will be in contact with you shortly regarding enrollment in the Beads of Courage Program.
Parent/Guardian First Name *
Parent/Guardian Last Name *
Child's First Name *
Child's Last Name *
Enrollment Age Requirements for the Beads of Courage Program -Under 21 years of age
Date of Birth (MM/DD/YYYY) *
CONTACT INFORMATION
Email Address *
Phone Number *
Mailing Address *
Address Line 2
City *
Province *
Postal Code *
PROGRAM INTEREST
Tell us about your interest in the BOC Program *
Where is your child (or yourself) being treated? *
How long has your child (or yourself) been in treatment?
Primary Specialist
Notes/Comments
OTHER INFORMATION
How did you hear about Beads of Courage? *
Newsletter Preference	Email Postal Mail Both None

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