Join BCA New Member Form First year membership is complimentaryFriend / Family Support Form Support costs $100.00 for Friends and Family supportersAlumni Support Form Alumni Pay It Forward Support is $100.00Contact InformationName* First Last Test Entry Test Submission - Will not be processed Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Cell Phone*Email* Enter Email Confirm Email HiddenAre you a:* New supporter Returning supporter Family / Friend Date MM slash DD slash YYYY How did you hear about us?Diagnosis InformationDid you receive your diagnosis in the last 12 months? Yes No New diagnosis informationSurgery Date MM slash DD slash YYYY Surgeon Hospital Tell us about yourself(Select all that apply) I have been diagnosed with breast cancer I am a friend or family supporter and a fan of the work of Breast Cancer Action Date of diagnosis MM slash DD slash YYYY Other InformationI would like to receive Breast Cancer Action email updates Yes You may opt out at any time. Breast Cancer Action does not sell, transfer or share client lists with any external sources. All personal information will remain confidential I would like to know more about Peer Support Program Health and Wellness Program Lymphedema Program The Kelly Project: The gift of a post-surgery camisole for those undergoing a mastectomy Pre-Op Sessions How did you hear about us?* Medical Practitioner Kelly’s Boutique Haley Rehab A mastectomy specialty store Supporter Referral Family / Friend Referral On-Line Which Specialty Store? Support and Donation OptionsSubsidize an additional Supporter or make a donation along with your registrationSupport Level First Year Supporter Alumni Supporter Friend / Family Supporter HiddenPromo Code General Donation ($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 Quantity: 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.)CAPTCHATotal $ 0.00 CAD Credit CardCard Details Cardholder Name
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