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.

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

“Strength, Light, Courage”.

Cancer Support Haldimand

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Date of Application

Application Information

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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:*

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Approximate date of diagnosis

Type of Cancer (if relevant):

Name of Treatment Facility:

Name of Oncologist:

Please explain how we can help you:*

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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*

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Date of Signature*

Please Help us Help Others

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