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: $ 75.00 CAD
Additional Support Options
- A Post-Op Camisole for a Newly Diagnosed Woman
- Subsidize a Health and Wellness Program membership
Total
$ 0.00 CAD
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
$ 0.00 CAD
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.

Donate TODAY!

Sponsor A Membership

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!