Get Involved

Pay It Forward Fundraising Program

New Member Form

First year membership is complimentary
Friend / Family Support Form

Support costs $100.00 for Friends and Family supporters
Alumni Support Form

Alumni Pay It Forward Support is $100.00
Contact Information
Name*
First Last
Test Entry
- Test Submission - Will not be processed
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Cell Phone*
Email*
Enter Email Confirm Email
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Are you a:*
- New supporter
- Returning supporter
- Family / Friend
Date
MM slash DD slash YYYY
How did you hear about us?
Diagnosis Information
Did you receive your diagnosis in the last 12 months?
- Yes
- No
New diagnosis information
Surgery Date
MM slash DD slash YYYY
Surgeon
Hospital
Tell us about yourself
(Select all that apply)
- I have been diagnosed with breast cancer
- I am a friend or family supporter and a fan of the work of Breast Cancer Action
Date of diagnosis
MM slash DD slash YYYY
Other Information
I would like to receive Breast Cancer Action email updates
- Yes
You may opt out at any time. Breast Cancer Action does not sell, transfer or share client lists with any external sources. All personal information will remain confidential
I would like to know more about
- Peer Support Program
- Health and Wellness Program
- Lymphedema Program
- The Kelly Project: The gift of a post-surgery camisole for those undergoing a mastectomy
- Pre-Op Sessions
How did you hear about us?*
- Medical Practitioner
- Kelly’s Boutique
- Haley Rehab
- A mastectomy specialty store
- Supporter Referral
- Family / Friend Referral
- On-Line
Which Specialty Store?
Support and Donation Options
Subsidize an additional Supporter or make a donation along with your registration
Support Level
- First Year Supporter
- Alumni Supporter
- Friend / Family Supporter
Hidden
Promo Code
General Donation ($CAD):
You will receive a tax receipt for donations over $25.00
I would like to subsidize another membership in addition to my own
- Yes
Subsidize another survivor ($CAD)
You will receive a tax receipt
Price: $ 100.00 CAD
Total
What YOU Get with your support
- Once registered with Breast Cancer Action, a gifted post-surgical camisole when visiting Kelly’s Boutique
- Free membership to Pink Cleaners and 50% of all dry cleaning https://pinkcleaners.ca/
- Unlimited access to our Peer Support Programs (group, one on one counselling or just having a coffee with someone who understands)
- Discounted tickets for Breast Cancer Action events
(When you click "Submit" you will be directed to PayPal.)
CAPTCHA
Total
Credit Card
Card Details
Cardholder Name

Taking part on Breast Cancer Action’s Pay It Forward Funding Program will ensure that the newly diagnosed will continue to receive:

Complimentary group, one on one and counselling partners programs
Unlimited access to our Health and Fitness Program
Gifted post-surgical camisole (Dr reference only and picked up at Kelly’s Boutique)
And much more…

Helping out is easy!

Questions about supporting? Call us at 613-736-5921

In order to begin enjoying all the privileges of helping Breast Cancer Action, you can support us using the following methods:

ONLINE: Fill out our simple online order form (On the left side of this page, or on a smartphone, scroll down).

VIA MAIL: Download our membership form. Please mail completed form, along with a cheque for the total amount to Breast Cancer Action.

All funds collected from our support program are invested back into the organization to offset the cost of operating the post-diagnosis support and resource centre. Breast Cancer Action does not share, or make known to outside sources our contact list.

Get Involved

Pay It Forward Fundraising Program

New Member Form

Friend / Family Support Form

Alumni Support Form

Contact Information

Diagnosis Information

New diagnosis information

Other Information

Support and Donation Options

What YOU Get with your support

Helping out is easy!