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 – one caregiver per participant)

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.

Program Details

Do you or your caregiver require transportation through CAP?

Yes

Do you or your caregiver have any accessibility needs or food allergies we should be aware of?

Yes

If yes, please describe:

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 or scheduling purposes.

Yes