Cancer Support Haldimand

The Community Support Centre Haldimand-Norfolk is committed to providing compassionate, accessible, and non-clinical cancer-related support to individuals and caregivers in Haldimand. Eligible participants are individuals living with cancer at any stage of their diagnosis residing in Haldimand County.

Some of the ways we can help include:

Assistance with meals
Transportation costs
Parking assistance
Personalized support

Our team is here to offer support, understanding and comfort as you navigate your cancer journey.

“Strength, Light, Courage”.

Cancer Support Haldimand Application For Assistance

"*" indicates required fields

Date of Application

Application Information

I am filling this form out:*

Click to select the answer that applies to your situation.

Applicant's Name*

First Last

Applicant's Email Address

Applicant's Phone Number

Recipient's Name*

First Last

Recipient's Home Address*

Street Address Address Line 2 City Province Postal Code

Home Phone

Cell Phone

Marital Status

Date of Birth

# of Dependents

Age of Dependents

Relationship with cancer:*

Click to select the answer that applies to your situation.

Approximate date of diagnosis

Type of Cancer (if relevant):

Name of Treatment Facility:

Name of Oncologist:

Please explain how we can help you:*

PLEASE NOTE: If you are requesting items, please ensure you include estimates/receipts

Upload estimates/receipts

Max. file size: 512 MB.

Applicant Release of Confidential Information

I certify that the above information is accurate, to the best of my knowledge. I also understand that this information is confidential and will not be released to others unless so directed by myself or unless law requires it. The information enclosed in the application will only be used for the CSH Program. I understand that my identity will be protected and kept confidential.

Applicant Signature*

Typing your name in the signature box acts as your signature.

Date of Signature*

Please Help us Help Others

How did you hear about the Cancer Support Haldimand?

What other ways could we be of assistance to Cancer patients and families?

We are partnering with our friends at South Coast Community Caring For Cancer. They
provide cancer care bags that are filled with thoughtfully chosen items including
personal care must haves, everyday comforts and support items to make your journey a
little easier. You can request a bag for yourself, a family member or a loved one residing
in Haldimand-Norfolk.

Request A Cancer Care Bag