Wishes of Hope Referral Form

Eligibility Criteria: Before submitting a referral, please review the following eligibility requirements:

Age & Location: Children between the ages of 3–17 living in the southeastern Manitoba region served by Southeast Cancer Support Services (SCSS).
Diagnosis: Active cancer diagnosis.
Who Can Refer: Referrals may be made by anyone, with prior approval of the family involved. They cannot be made anonymously.

For questions about eligibility or the referral process, please contact us at info@secancersupport.ca or call
204-846-HOPE (4673)

THANK YOU TO OUR PROGRAM SPONSORS

Program Supporters:

Your Full Name

Your Email Address

Your Phone Number

Your Relationship to the Child

Family Permission Family Permission The Parent/Guardian of the Child has agreed to allow this referral

Child's Full Name

Child's Birthday (MM/DD/YY)

Child's Gender Child's Gender Male Female Other

Cancer Diagnosis

Date of Diagnosis

Physician's Name

Treatment Hospital/Clinic

Child is located in:

Child's Address

City/Town

Postal Code

Family Email

Family Phone

Parent/Legal Guardian 1 - Full Name

Parent/Legal Guardian 1 - Email

Parent/Legal Guardian 1 - Phone

Parent/Legal Guardian 2 - Full Name

Parent/Legal Guardian 2 - Email

Parent/Legal Guardian 2 - Phone

Where did you hear about Wishes of Hope?

Do you have a wish option you feel the child would appreciate/has requested?

Any additional comments:

4 + 10 =

Founding Partners