New Client Registration

New Client Registration Form

*If using a wheelchair, someone must accompany you who can lift the wheelchair and provide support

ACCOMMODATIONS

Do you require any accommodations for sight, hearing or mobility?

Do you have any dietary restrictions or allergies we need to be made aware of?

LANGUAGE

The Cancer Assistance Program utilizes an over the phone interpretation service to better serve our communities. If you would like to use this service when communicating with CAP, please provide the language below.

Preferred Language

CLIENT INFORMATION

Are you from one of the following communities?

Six Nations of the Grand River

Mississaugas of the Credit

First/Preferred Name

Last Name

Birthdate

Gender

What are your preferred gender pronouns?

Address

Address Line 1

Address Line 2

City

Postal Code

Primary Phone

Secondary Phone

Preferred Method of Contact

Phone

Both

ALTERNATE CONTACT INFORMATION

Primary Contact

Alternate Contact Primary Phone

Alternate Contact Email

First/Preferred Name

Last Name

Relationship

Alternative Contact Secondary Phone

Alternative Contact Address

Address Line 1

Address Line 2

City

Postal Code

SERVICE CRITERIA

Type of Cancer

Where are you currently receiving care?

Are you currently connected with a social worker/occupational therapist/physiotherapist?

Yes

Please list name and phone number of social worker, OT or physiotherapist

Are you registering because you’ve recently been discharged from the hospital?

Yes

How did you hear about CAP?

TRANSPORTATION

Our Drive and Ride program is available only to residents in the Greater Hamilton Area.

We apologize for any inconvenience.

Will you be requiring transportation services?

Yes

Do you require assistance getting in and out of a vehicle?

Yes

I will have someone accompany me on all rides to provide this support.

Are you able to get in and out of a van or SUV?

Yes

Will you be using any of the following assisted devices?

Rollator

Walker

Wheelchair

Oxygen

None

*If using a wheelchair, someone must accompany you who can lift the wheelchair and provide support

Pick-up Specifications: Which entrance or which road to enter from?

Other relevant information

I understand and agree that all clients using our Drive & Ride program are required to wear a MASK and SEAT BELT.

I have read and agree to the Privacy and Equipment Statement.