Join BCA Step 1 of 3 33% Contact InformationName* First Last Test Entry Test Submission - Will not be processed Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Cell Phone*Email* Enter Email Confirm Email Are you a:*New memberReturning memberFamily / FriendDate Date Format: MM slash DD slash YYYY How did you hear about us? Did you receive your diagnosis in the last 12 months?YesNoNew diagnosis informationSurgery Date Date Format: MM slash DD slash YYYY SurgeonHospitalI would like to receive BCA email updatesYou 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 YesNoTell us about yourself(Select all that apply) I have been diagnosed with breast cancer I am a friend or family member and a support of the work of Breast Cancer Action Date of diagnosis Date Format: MM slash DD slash YYYY 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 Busting Out Dragon Boat Program How did you hear about us?*Medical PractitionerKelly’s BoutiqueHaley RehabA mastectomy specialty storeMember ReferralFamily / Friend ReferralOn-LineWhich Specialty Store? Membership and Donation OptionsMembership OptionStandardRegular Membership (pro-rated 2020)Regular Membership & Fitness (pro-rated 2020)Membership Fee*Regular/ Renewal (1 year January 1 - December 31): $75Supporter (1 year - January 1 - December 31): $50Depending on when you join throughout the year, pro-Rated membership is available. All Renewals are due December 1 for the following year. Please contact the office for your membership fee and processing.Family / Friend*Family / Friend Membership (1 year - January 1 - December 31): $100)Depending on when you join throughout the year, pro-Rated membership is available. All Renewals are due December 1 for the following year. Please contact the office for your membership fee and processing.Promo CodeInitial Diagnosis Discount First Year Initial Diagnosis Discount First Year Pro-rated Price* Options Select All Fitness Membership Dragon Boat Busting Out Member Options Select All Fitness Membership Dragon Boat Busting Out Member Options Select All Fitness Membership Dragon Boat Busting Out Member General Donation ($CAD):You will receive a tax receipt for donations over $25.00 Subsidize a Membership ($CAD)You will receive a tax receipt Price: $ 50.00 CAD Quantity: Total $ 0.00 CAD What YOU Get with your Membership Once registered with BCA, a gifted post-surgical camisole when visiting Kelly’s Boutique One free consultation with Haley Rehab http://haleyrehab.ca/ and access to our Lymphedema program. Free membership to Pink Cleaners and 50% of all dry cleaning https://pinkcleaners.ca/ Unlimited access to our health and wellness program for the year. Our Health and Wellness Fitness program are designed specifically for someone with breast cancer. Unlimited access to our Peer Support Programs (group, one on one counselling or just having a coffee with someone who understands) Membership tickets discounts for BCA events (When you click "Submit" you will be directed to PayPal.)CAPTCHACredit CardPlease create a Square feed.
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