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THRIVE SUPPORT PROGRAM APPLICATION FORM

Please read this form carefully and complete all sections prior to submission, including the Eligibility Checklist and the Terms and Conditions. Please also upload a separate Letter of Intent outlining your (the applicant’s) health story and why you are seeking funding from Thrive Alive Foundation (1-2 pages). All information marked with a * (red star) is required to properly process and review the application. Incomplete applications will NOT be processed.

Thrive Alive Foundation does not give medical advice or make recommendations on what services would be suitable for a person. As the applicant, you need to know the exact service(s) you are requesting. If you are seeking support from more than one healthcare provider, you need to choose one.

Your application is a multi-step process (detailed here). Upon submission of this application form and Letter of Intent, your application will be committee reviewed and you will be contacted by email regarding the status of your application. Please include a valid email address in this application.

ELIGIBILITY CRITERIA CHECKLIST

ALL applicants must meet the following criteria: Note that further supporting documentation may be required

Canadian citizen or permanent resident? *

Be a Canadian citizen, or permanent resident, and living in Canada;

Low income status? *

Qualify as low-income, according to Statistics Canada, and provide proof with an income tax Notice of Assessment;

Cancer diagnosis? *

Have a cancer diagnosis, to be confirmed with an oncology report direct from hospital or cancer agency;

Legal guardianship consent (if necessary)? *

Provide reference and consent of legal guardianship, if 16 years of age or younger, with legal guardians prepared to supply supporting documents, and;

Service or treatment chosen? *

Already know the service, treatment and/or health practitioner in Canada of which you are requesting funding support.

LETTER OF INTENT

A Letter of Intent is required for all applicants: *Please save and upload your document in Adobe PDF (.pdf), MS Word (.doc/.docx), or Open Document (.odt) formats only; all others will be rejected by our system.
The maximum size of the document allowed is 5MB.

BASIC INFORMATION

First Name *
Last Name *
Address *
City *
Province *
Postal Code *
Country *
Daytime Phone
Evening Phone *
Mobile Phone
Date of Birth *MM/DD/YY format
Age *
Gender *
MaleFemaleUnspecified
Email Address *

HOUSEHOLD INFORMATION

How many persons live in your household? *
How many dependents live in your household? *

MEDICAL INFORMATION

If selected, you will be required to provide your provincial health care number as well as supporting documents of your cancer diagnosis which will come from your medical team.
Cancer Diagnosis *
Date of Cancer Diagnosis *MM/DD/YY format
Referring Physician *
Current Treatments: *
Please list all that apply
Description of services that you are seeking: *
Please list all that apply

TERMS AND CONDITIONS

COLLECTION OF INFORMATION / PRIVACY Any personal information provided to Thrive Alive Foundation is collected, used and disclosed is accordance with the Freedom of Information and Privacy Act or other applicable legislation. Purpose for collecting information: Thrive Alive Foundation will be collecting and using the information to assess and process the application, verify the details of your health case, and for statistical data collection purposes. Personal information will not be sold, traded, given or disclosed to any other body or organization. Personal information will only be collected and used by authorized staff and members of Thrive Alive Foundation to fulfill the purpose for which it was originally collected. Thrive Alive Foundation does not collect personal information unless voluntarily provided for the Thrive Support Program application. All information marked with a * (red star) is required to properly process and review the application, unless clearly specified.

DISCLAIMER Thrive Alive Foundation will not be responsible for harm or loss incurred from receiving care or treatments or products from the health care provider chosen or monetary grant from Thrive Alive Foundation. By submitting this application you, the applicant, release Thrive Alive Foundation from any and all claims related to this application and the use of treatments or products received as a result of it. BY SUBMITTING YOUR APPLICATION, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTOOD ALL TERMS OF APPLICATION AND FURTHER CONSENT TO THE USE OF THE COLLECTION AND USE OF YOUR PERSONAL INFORMATION AND THAT YOU ARE WAIVING YOUR LEGAL RIGHTS TO TAKE LEGAL ACTION AGAINST THRIVE ALIVE FOUNDATION. IT IS AN OFFENCE TO MAKE A FALSE OR MISLEADING STATEMENT IN AN APPLICATION FOR SUPPORT THROUGH A REGISTERED CHARITABLE ORGANIZATION.

APPLICATION CHECKLIST

Please check that you have completed the following tasks BEFORE submitting:

Letter of Intent included? *

I’ve included a Letter of Intent for upload with my application.

Understand Eligibility criteria? *

I’ve read and understood the Eligibility Criteria listed at the outset of my application.

Understand Terms and Conditions? *

I’ve read and understood the Terms and Conditions stated above.

APPLY NOW

THRIVE SUPPORT PROGRAM APPLICATION FORM

ELIGIBILITY CRITERIA CHECKLIST

LETTER OF INTENT

BASIC INFORMATION

HOUSEHOLD INFORMATION

MEDICAL INFORMATION

TERMS AND CONDITIONS

APPLICATION CHECKLIST

Verification

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