Applicant Information (for the CAP client)

First Name

Last Name

Phone/Mobile

Email Address

Address Line 1

City

Province

Postal Code

Are you currently receiving services through CAP?

Yes

Caregiver Information (optional)

First Name

Last Name

Phone/Mobile

Relationship to Applicant

Tell Us a Bit More

We expect a high level of interest in this program. Please take a moment to share why attending Artful Moments would be meaningful to you and your caregiver. Your response helps us understand your interest and ensure a good fit for all participants.

Consent

I understand that Artful Moments is a non-clinical, recreational art experience and not a support group or art therapy session.

Yes

I give the Cancer Assistance Program permission to share a photo or digital copy of my artwork from the Artful Moments experience in CAP’s promotional materials, social media, or reports. I understand that my name will not be included unless I give additional consent.

Yes

I agree to be contacted by the Cancer Assistance Program for follow-up purposes.

Yes