EmailMe Form - BrainWAVE Pediatric Program Membership Form

Last Name: *

Parent(s) or Guardian(s) Names: *

First Last

Parent(s) or Guardian(s) Names:

First Last

Name of child with a brain tumour (under 19 yrs of age): *

First Last

Child's Date of Birth: *

MM / DD / YYYY

Names and ages of siblings:

Email: *

Telephone: *

### - ### - ####

Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

The following information helps us to best plan programs and services for everyone affected by a brain tumour. This section is optional and all information is kept confidential.

How did you hear about us?

Brain Tumour Type:

Malignant

Non - Malignant

Mixed Grade

Unknown/Waiting on Pathology

Release and Indemnity:

Photograph Note: Please note that photos may be taken as part of a BrainWAVE event or activity. You will be contacted if we would like to use a photo with your family. Should you wish your family’s photo not be taken, please notify staff.

Brain Tumour Foundation of Canada respects your privacy. We protect your personal information and adhere to all legislative requirements with respect to privacy. We do not rent, sell, or trade our mailing lists. The information you provide will be used to assist us in delivering services and keeping you informed about the activities of Brain Tumour Foundation of Canada, including programs, services, special events, funding needs and opportunities to volunteer.

Please contact us if you have any questions.
www.braintumour.ca 1-800-265-5106