subject_line

One Mile at a Time Transportation Program

Applicant Eligibility

I am: * 🛈

Eligibility criteria * 🛈

I reside in Canada

I have a blood cancer diagnosis

I have a minimum of 4 medical appointments related to my blood cancer diagnosis at a recognized cancer treatment facility in Canada.

I can provide a medical appointment schedule or email/note from a health care professional stating I still have a minimum of 4 medical appointments at a cancer center.

Eligibility criteria
The person I am applying for: * 🛈

Resides in Canada

Has a blood cancer diagnosis

Has a minimum of 4 medical appointments still required related to his or her blood cancer diagnosis at a recognized cancer treatment facility in Canada.

Has a medical appointment schedule or email/note from a health care professional stating he or she will have at least a minimum of 4 medical appointment at a cancer center.

Please attach appointment schedule, or email or letter.

Applicant Details

Details on caregiver

Full Name *

Email *

Phone Number (Home)

Phone Number (Cell) *

Mailing Adress *

City *

Province *

Date of Birth * 🛈 +

Diagnosis *

Name of Cancer Treatment *

Date of Diagnosis * 🛈 +

Details on person applying for the program

Full Name *

City *

Province *

Date of Birth * 🛈 +

Diagnosis *

Name of Cancer Treatment *

Date of Diagnosis * 🛈 +

Staying connected with the LLSC

I would like more information on: 🛈

Blood cancers (LLSC print materials, online resources)

Information Resource Center (Medical information, clinical trials, nutrition support)

Practical support programs (financial assistance)

Psychosocial support programs (First Connection, support groups, mental health resources, Your Life After Cancer program)

Upcoming LLSC patient education session (webcasts)

I would like to receive communications about LLSC’s programs and services. *

Yes

I understand that the confidential information will be utilized by the LLSC for program management purposes. *

I agree

© 2003-2018 The Leukemia & Lymphoma Society of Canada

National Office location
804 - 2 Lansing Square, Toronto, ON M2J 4P8
1-877-668-8326 EN / 1-866-637-0281 FR
Lightthenight_ONO@lls.org

Security | Privacy | Link | Disclaimer
Charitable Business No. 10762 3654 RR0001